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THE 

IKEIGATION   TREATMENT 


OF 


G  O  N  O  R  R  H  (E  A 


ITS 


LOCAL  COMPLICATIONS  AND  SEQUELJ: 


BY 

FEED.  C.  VALENTINE,  M.D. 

Professor  of  Genito-Drinart  Diseases,  New  York  school  of  Clinical  medicine; 
Genito-Urinary  Surgeon,  West  Side  German  Dispensary;  Genito- 
urinary CONSULTANT  TO  THE  UNITED  HEBREW  CHARITIES 

to  the  metropolitan  hospital  and 
Dispensary,  etc.,  etc. 


ILLUSTRATED    BY    FIFTY-SEVEN     ENGRAVINGS 


NEW   YORK 
WILLIAM   WOOD   AND   COMPANY 

MDCCCC 


Copyright,  1900 
By  WILLIAM   WOOD  AND   COMPANY 


Y25 


THE    PUBLISHERS'    PRINTING    COMPANY 
32-34  LAFAYETTE  PLACE,   NEW  YORK 


npHE  GEKEEAL  PEACTITIONEE,  more  particularly  he  who  labors  in 
the  smaller  communities,  must  be  a  specialist  in  all  branches  of  medicine. 
The  demands  upon  his  waking  and  sleeping  hours  are  usually  so  great  that 
time  is  not  his  for  extensive  literary  research  or  for  the  study  of  exhaustive 
theoretical  volumes. 

Herein  lies  the  motive  for  the  present  effort  of  the  writer  to  offer  as  con- 
cisely as  possible  the  essential  facts  in  connection  with  the  treatment  of  gonor- 
rhoea, and  to  place  before  the  busy  practitioner  the  results  of  his  experience. 
The  General  Practitioner,  who  conscientiously  exercises  his  power  to 
benefit  mankind,  must  treat  gonorrhcea  when  called  upon  to  do  so  ;  and  he 
must  treat  it  in  a  manner  that  will  protect  his  patients  and  the  public  from 
the  consequences  of  this  disease.  Furthermore,  it  is  the  work  of  the  General 
Practitioner  which  forms  the  firm  foundation  upon  which  the  superstnicture 
of  medical  specialism  is  built ;  therefore, 

TO 
THE   GENERAL   PRACTITIONER 

THIS   LITTLE   BOOK 
IS   FEATERNALLY   DEDICATED 


INTRODUCTIOISr. 


The  larger  and  better  works  on  genito-urinary  diseases  fully 
discuss  gonorrhoea.  Unfortunately  none  of  them,  except  the 
master- work  of  Guy  on, '  makes  much  more  than  casual  mention 
of  the  irrigation  treatment  of  this  ever-prevalent,  painful  dis- 
ease, which  when  empirically  treated  is  likely  to  be  fraught 
with  most  disastrous  consequences. 

It  is  the  purpose  of  this  little  book  to  fill  the  hiatus,  until 
abler  pens  supply  the  missing  chapter  in  new  editions  of  their 
works. 

1  Guyon :  Legons  cliniques  sur  les  Maladies  des  Voies  urinaires,  troisi^me 
Mition,  Paris,  1894. 


THE    IRRIGATION    TREATMENT   OF 
GONORRHCEA. 


GENERAL  CONSIDERATIONS. 

Goldberg'  was  the  first  to  subject  the  results  of  the  irriga- 
tion treatment  of  gonorrhoea  to  mathematical  tests.  He  summed 
up  the  publications  of  all  who  had  written  favorably  or  other- 
wise on  the  method,  and  showed  that  these  reported : 

60  per  cent,  of  acute  gonorrhosas  cured  within  10  days, 
30    "      "       "       "  "  "  "       14  days, 

10    "      "       "       "  "  were  not  cured. 

Of  the  last  mentioned — one-tenth  of  the  cases — the  failure  was 
clearly  attributable  in  one-half  of  them  to  indulgence  in  alcohol 
and  coitus,  and  the^  remaining  five  per  cent,  were  not  explained. 
These  failures  in  the  hands  of  such  authors  will  probably  find 
their  explanation  in  those  rapid  invasions  of  the  urethral  adnexa 
which  will  be  considered  later  on  in  discussing  the  complications 
of  gonorrhoea. 

At  all  events,  no  method  of  treating  gonorrhoea  offers  as  many 
scientific  grounds  for  its  employment,  and  not  another  can  show 
ninety  per  cent,  of  cases  cured  ivitliin  fourteen  days. 

That  a  large  number  in  the  profession  appreciate  this  is 
shown  by  the  following  facts : 

In  1894  not  a  dozen  men  in  the  world  were  using  the  irriga- 
tion treatment  in  gonorrhoea.  Many  had  attempted  and  dis- 
carded it,  owing  to  defective  apparatus;  others  had  obtained 
negative  or  unfortunate  results,  owing  to  faulty  technique.  In 
face  of  the   adverse   criticisms   these   conditions    provoked,   it 

'  Goldberg:  "Die  Behandlung  der  Gonorrhoe  mit  Ausspuhmgen  von  iiber- 
mangansaurem  Kali."    Centralblatt  fur  die  Krankheiten  der  Ham-  und  Sexual- 
Organe,  Band  vii.,  Hefte  3  l^nd  4. 
1 


2  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

required  commendable  courage  on  the  part  of  Felicke  of  Buda- 
pest, Janet  of  Paris,  E.  R.  W.  Frank  of  Berlin,  and  Swin- 
burne of  New  York  to  persist  in  a  method  in  which  then,  they 
alone  succeeded. 

Some  time  before,  I  was  convinced  of  the  results  obtainable 
and  of  the  opportunities  offered  for  advancing  gonorrhoea  from 
its  empiric  therapeutic  chaos.  It  seemed  to  me  that  if  the  pro- 
fession at  large  were  offered  an  apparatus  by  which  irrigations 
might  be  easily  and  correctly  performed,  the  advantage  to 
science  and  to  patients  would  be  more  readily  appreciable. 
There  is  no  purpose  in  reciting  the  evolution  of  the  apparatus. 
It  will  suffice  to  describe  herein  the  last  result  of  six  modifica- 
tions, the  one  now  used. 

The  middle  of  1899  shows  about  six  thousand  physicians  in 
the  United  States  alone,  using  the  irrigation  method,  errone- 
ously called  the  "Valentine  method,"  of  treating  gonorrhoea. 
I  did  nothing  except  devise  a  simple  apparatus,  develop  the 
technique,  modify  the  medications,  render  the  rules  precise, 
and  write  many  articles,  carefully  weighing  the  advantages  and 
avoidable  disadvantages  of  the  irrigation  treatment. 


I.  THE    IHRIGATORi 

This  apparatus  consists  of  a  board  (Fig.  1,  a  a)  with  a  brass 
rod  attached  (g).  Eeadily  sliding  upon  the  brass  rod  is  a  metal 
block,  connected  by  a  strong  bar  to  a  collar  (c).  This  firmly 
holds  a  percolator  (h)  of  a  capacity  of  1,000  c.c.  (about  one 
quart).  The  opening  that  interrupts  the  completeness  of  the 
collar  permits  easy  removal  of  the  percolator  when  required. 
The  nipple  of  the  percolator  is  inserted  into  a  soft-rubber  tube 
(0  seven  feet  long.  The  distal  end  of  this  rubber  tube  is 
Ijassed  through  a  stopcock,  whose  essential  parts  are  a  ring  (j) 
for  admission  of  the  fourth  finger ;  a  sliding  flange  (k)  to  increase 
or  decrease  the  pressure  of  the  fluid;  a  shield  (/)  to  catch  the 
fluid  that  spurts  from  the  urethra  and  divert  it  into  a  basin  held 
by  the  patient ;  a  small  ring  (m)  to  suspend  the  stopcock  when 
not  in  use.  Fig.  1  shows  a  urethral  nozzle  (n)  inserted  into  the 
rubber  tube,  projecting  through  the  stopcock. 

The  board  has  brass  plates  above  and  below  perforated  for 


THE   IRRIGATOR. 


screws,  by  means  of  whicli  the  apparatus  is  attached  to  tlie  wall. 

At/,  in  Fig.  1,  a  liook  attached  to  the  lower  end  of  the  board  is 

shown.     This  hook  holds  a  ring  at  the  end  of  a  stout  cord. 

The  cord  passes  over  a  pulley 

(d)   and  is    fastened   to   the 

travelling     block    mentioned 

before. 

The  variations  of  pressure 
required  for  anterior  and  in- 
travesical irrigations  are  ac- 
complished by  the  action  of 
the  right  thumb  and  index 
finger  on  the  stopcock,  and 
not  by  variations  in  the  height 
of  the  percolator.  Its  eleva- 
tion is  always  the  same;  it 
is  lowered  only  for  the  pur- 
pose of  filling  or  cleaning. 

Reference  to  Fig.  1  show^s 
ioo  clearly  to  merit  further 
study,  the  manner  in  which 
the  parts  of  the  apparatus 
are  put  together. 

Experience  has  demon- 
strated that  when  the  top  of 
the  irrigator  board  is  attached 
to  the  wall  at  an  elevation  of 
nine  feet  from  the  floor,  suffi- 
cient pressure  is  obtained 
for  all  purposes.  With  in- 
creasing experience  the  phy- 
sician finds  that  seven  and 
one-half  feet  elevation  suffices. 

It  will  be  found  conven- 
ient to  devote  a  little  study  to  the  stopcock  and  nozzles,  de- 
spite their  simplicity. 

If  the  stojjcock  is  taken  in  the  right  hand,  and  the  fourth 
(ring)  finger  passed  through  the  large  ring  on  the  metal  tube, 
the  thumb  and  index  finger  will  easily  reach  and  control  the 
flange.     On  pushing  it  forward  it  compresses  the  clips,  narrow- 


FIG. 


1.— Author's  Urethral  and   Intravesical 

Irrigator. 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


Fig.  3.— Author's  Stopcock. 


ing  or  even  closing  the  lumen  of  the  rubber  tube;  on  drawing  it 
back,  the  rubber  tube  resumes  its  entire  calibre.  One  or  two 
efforts  will  teach  the  physician  to  allow  single  drops  to  escape 

from  the  nozzle.  By 
gradually  drawing  back 
the  flange  the  stream  is 
increased  until  a  strong 
jet  carries  over  six  feet. 
All  variations  in  the 
flow,  from  mere  drops 
to  strong  jet,  are  accom- 
plished with  the  percolator  raised  to  its  greatest  height,  nine 
feet  from  the  floor.  The  value  of  so  controlling  the  flow  by 
slight  contraction  of  the  thumb  and  index  finger  will  become 
more  evident  on  considering  the  technique  of  irrigations. 

The  nozzles  are  of  glass  that  can  be  easily  sterilized.  Their 
shapes  are  shown  in  Fig.  3.  ^  is  a  pointed  nozzle,  for  irrigat- 
ing a  normal  meatus.  It  is  important  that  the  irrigating  fluid 
have  as  easy  exit  as  it  has  entrance  into  the  urethra.  The 
point  of  this  nozzle  allows 
washing  the  entire  ure- 
thra and  the  meatus  as 
well. 

i?  is  a  dome-shaped 
nozzle  devised  to  accom- 
plish anterior  and  pos- 
terior irrigations  without 
changing  the  nozzle, 
when  a  meatus  is  congen- 
itally  very  large  or  has 
been  made  so  by 
meatotomy. 

0  is  a  blunt 
nozzle  for  use 
when  a  congen- 
itally  very  small 

(pin-point)  meatus  would  otherwise  prevent  irrigation,  or  when 
the  normal  meatus  is  so  swollen  as  to  prevent  the  introduction 
of  nozzle  A.  Its  orifice  then  is  merely  pressed  against  the 
meatus  and  the  stream  so  directed  through  it  into  the  urethra. 


JP- 


D 


Nozzle  A  for  normal  meatus. 


Nozzle  B  for  large  meatus. 


Nozzle  C  for  small  meatus. 


Nozzle  D  for  female  urethra. 


Fig.  3.— Glass  Nozzles. 


THE   IRRIGATOR.  5 

D  is  devised  for  irrigations  of  the  female  urethra  and  bladder. 
Its  shape  is  the  same  as  nozzle  A  ;  its  length,  however,  is  three 
times  greater.  The  reason  for  its  increased  length  lies  in  the 
fact  that  all  females  must  be  irrigated  in  the  recumbent  posture, 
and  for  the  protection  of  the  thighs  from  soiling  with  the  irri- 
gating fluid  as  well  as  for  self-evident  anatomical  reason,  the 
shield  must  be  brought  down  between  the  thighs.  If  the  nozzle 
were  as  short  as  the  others,  the  shield  would  prevent  it  coming 
into  contact  with  the  meatus. 

Attachment  of  Nozzles. — The  nozzle  appropriate  for  the  size 
of  meatus  being  selected  with  sterilized  fingers,  its  tubular  end 
is  easily  inserted  into  the  rubber  tube  projecting  through  the 


Fig.  4.— Manner  of  Attaching  a  Nozzle. 

stopcock.  After  the  tubular  end  of  the  nozzle  is  firmly  inserted, 
the  rubber  tube  should  be  drawn  backward  until  the  shoulder  of 
the  nozzle  is  arrested  by  the  metal  projection  of  the  stopcock. 
This  then  holds  the  nozzle  firmly,  making  it  practically  one 
piece  with  the  stopcock. 

As  this  book  may  fall  into  the  hands  of  one  or  another  prac- 
titioner not  especially  so  endowed  that  he  readily  grasps  me- 
chanical ideas,  I  have  thought  well  to  be  explicit,  even  to  verbos- 
ity, in  the  above  directions  for  use  of  the  stopcock  and  nozzles. 

Another  form  of  this  irrigator  was  modified  from  suggestions 
submitted  to  me  by  M.  Wocher  &  Son,  of  Cincinnati.  The  illus- 
tration shows  that  in  this  apparatus  a  metal  bracket  takes  the 
place  of  the  board  previously  described.  The  rubber  tube  ex- 
panded and  reinforced  will  not  slip  out  of  the  stopcock,  and 
therefore  requires  no  nozzle  or  closing  of  the  clips  to  retain  it. 
A  supplementary  bracket  (s)  receives  and  holds  the  percolator 
when  it  is  let  down  to  be  filled.  The  graceful  form  of  this  irri- 
gating apparatus  appeals  to  many  practitioners,  especially  those 
to  whom  economy  in  office  space  is  an  object. 

Care  of  the  Irrigator. — Despite  the  simplicity  of  the  apparatus 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


it,  like  any  other,  would  not  only  become  unsightly,  but  its  util- 
ity destroyed  by  uncleanli- 
ness. 

To  preserve  the  apparatus 
and  to  have  it  always  ready 
for  work,  it  will  be  well  to  ob- 
serve the  following  rules : 

1.  When  not  in  use,  keep 
the  flange  of  the  stopcock 
well  drawn  back,  so  as  to 
have  no  compression  whatever 
of  the  rubber  tube. 

2.  When  the  first  described 
form  of  irrigator  is  used,  keep 
a  clean  nozzle  inserted  in  the 
rubber  tube  to  prevent  the 
tube  slipping  out  of  the  stop- 
cock. Its  shoulder  will  hold 
the  rubber  tube  in  place.  With 
the  bracket  irrigator,  as  men- 
tioned above,  this  precaution 
is  not  necessary, 

3.  To  prevent  the  formation 
of  angles  in  the  rubber  tube, 
which  would  eventually  cause 
it  to  break,  and  to  reduce  the 
strain  upon  the  part  of  the  tube 
into  which  the  percolator's 
nipple  is  inserted,  hang  the 
stopcock  mounted  as  above 
described,  by  its  small  ring 
upon  a  cup-hook  conveniently 
placed  for  the  purpose. 

4.  Thoroughly  wash  the  ir- 
rigator each  time  after  it  has 

been  used.  Ordinarily  it  will  suffice  to  let  hot  water  run  through 
it  several  times.  Although  the  percolator  may  not  be  visibly 
stained,  it  should  be  remembered  that  permanganate  of  potassium 
tends  quickly  to  destroy  the  rubber  tube.  It  will  be  preserved 
almost  indefinitely  if  this  rule  is  observed. 


Fig.  5. — Modified  Braclcet  Irrigator. 


THE   IRRIGATOR.  7 

5.  Should  the  percolator  become  soiled,  let  a  strong  solution 
of  oxalic  acid  run  through  it.  If  this  does  not  suffice,  use  the 
oxalic  solution  on  cotton  mops  to  rub  out  the  stains.  Fill  the 
percolator  at  least  three  times  with  clean  hot  water  after  using 
oxalic  acid,  lest  some  remain  and  be  accidentally  injected  into 
the  urethra  or  bladder. 

6.  After  each  use  wash  all  parts  of  the  shield  with  soap  and 
hot  water,  rub  it  with  cotton  soaked  in  bichloride  1 : 1,000,  dry 
it  and  hang  upon  its  hook.  This  precaution  will  prevent  the 
possible  carrying  of  infection  to  another  patient.  While  it  is 
true  that  the  majority  of  cases  irrigated  have  gonorrhoea,  there 


Fig.  6.— Manner  of  Suspending  Stopcock. 

is  no  reason  for  the  physician  to  expose  them  to  new  infection. 
On  the  other  hand,  many  patients  needing  irrigations  are  not 
gonorrhceal,  as,  for  example,  cases  requiring  urethral  or  vesical 
instrumentation  or  cases  of  contracted  bladder.  They  certainly 
should  not  be  exposed  to  gonorrhceal  infection  which  can  be 
avoided  by  the  simple  precautions  of  cleanliness. 

7.  It  would  be  criminal  negligence  to  subject  any  patient  to 
the  danger  of  infection  by  using  a  nozzle  that  has  been  employed 
in  the  previous  case.  This  danger  is  easily  avoided  by  the  fol- 
lowing steps : 

(a)  Immediately  after  irrigation  hold  the  shield  with  the 
used  nozzle  still  in  place,  under  boiling,  running  water. 

(b)  Remove  the  nozzle  and  place  it  into  a  strong  bichloride 
solution,  kept  ready  in  a  glass  dish  for  that  purpose. 

(c)  When  the  day's  office  work  is  done,  boil  aU  the  used 
nozzles  for  ten  minutes  in  strong  caustic  soda  solution. 


8  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

(d)  After  boiling,  place  the  nozzles  in  a  strong  (1:1,000) 
bichloride  solution,  kept  in  a  covered  glass  or  china  dish  re- 
served for  sterilized  nozzles, 

(e)  Rinse  each  nozzle  again  in  clean  hot  water  before  using. 

(/)  While  the  steps  described  in  a  to  e  suffice  for  the  steril- 
ization of  nozzles,  it  is  not  amiss  to  take  extra  precautions  when 
a  syphilitic  has  been  irrigated.  In  a  large  practice  where  many 
nozzles  are  used,  it  is  well  to  break  the  nozzle  after  employing 
it  on  a  case  with  lues.  If  economj^  prompts  keeping  such  noz- 
zles, each  one  should  be  boiled  separately  and  kept  in  a  test 
tube  filled  with  mercuric  bichloride,  1  to  1,000.  The  test  tube 
may  be  closed  with  a  rubber  cork,  marked  with  a  number  or 
letters  to  designate  the  patient  for  whom  the  nozzle  is  used. 

The  indications  for  irrigations,  their  technique,  and  the 
solutions  employed  will  be  considered  under  the  special  heads 
where  they  properly  belong. 


II.    ACUTE  ANTERIOR   GONORRHCEA. 

In  intromission  during  sexual  intercourse  the  lips  of  the 
meatus  are  more  or  less  pressed  apart,  causing  the  meatus  to 
gape.  On  each  withdrawal  the  lips  are  pressed  together  by  the 
same  vaginal  pressure  that  pressed  them  apart  on  insertion. 
This  gives  the  meatus  a  motion  which  may  be  compared  to  the 
opening  and  closing  of  a  fish's  mouth  when  feeding.  If  the 
vagina  harbors  gonococci,  and  if  the  penis  is  part  of  a  body 
with  lowered  resistance,  the  infection,  however  reduced  in  the 
female,  will  fijid  a  new  culture  ground  in  the  male  urethra. 

In  contravention  to  this  it  may  be  offered  that  gonorrhoea 
most  frequently  affects  men  in  the  best  possible  physical  condi- 
tion. It  is  equally  true,  though,  that  men  in  full  vigor  are  the 
most  likely  to  expose  themselves  to  venereal  infection. 

Again,  a  number  of  persons  appear  who  contracted  gonorrhoea 
without  intromission,  such  as,  for  instance,  when  emission  of 
semen  took  place  before  the  penis  could  be  inserted  into  the 
vagina.  These  are  easily  explained  by  the  fact  that  the  female 
urethra  and  Bartholini's  glands  are  a  very  frequent  site  of  re- 
sidual gonorrhoea. 

Extra-genital  gonorrhoea,  i.e.,  its  acquisition  otherwise  than 


ACUTE  ANTERIOR  GOXORRHCEA.  9 

from  an  infected  female,  as  for  instance  from  a  water-closet,  is 
improbable,  unless  a  man  with  an  immense  meatus  were  to  reck- 
lessly smear  it  over  the  seat  upon  which  gonorrhoeal  discharge 
had  been  left  by  another/  Taylor'  says  that  the  acquisition  of 
gonorrhoea  on  a  "  foul  privy  or  urinal  may  be  looked  upon  as  a 
euphemism  to  be  used  in  the  case  of  some  clerical,  venerable, 
or  married  transgressor." 

One  distinct  case  of  extra-genital  gonorrhoeal  infection,  how- 
ever, came  under  my  observation  in  1897.  A  gentleman  had 
contracted  gonorrhoea  fifteen  years  before.  The  case  was  per- 
sistent and  followed  by  stricture,  for  which  his  physician  used 
sounds.  These  had  been  discontinued  for  several  years.  The 
patient  had  for  five  years  been  engaged  in  severe  mental  labor, 
during  which,  as  happens  under  such  circumstances,  he  experi- 
enced no  sexual  desire.  A  few  months  before  being  sent  to  me 
he  became  engaged  to  be  married.  He  had  forgotten  everything 
connected  with  his  former  gonorrhoea  and  stricture.  Two 
months  before  the  day  set  for  his  wedding,  this  gentleman, 
while  in  the  rooms  of  a  friend,  saw  a  sound  lying  on  the  wash- 
stand.  It  was  a  30  F,  the  same  number  he  had  last  used.  To 
ascertain  whether  his  urethra  had  preserved  its  calibre,  he  es- 
sayed introduction  of  the  sound  into  his  own  urethra,  and  found 
no  difficulty  in  doing  so.  Three  days  later  he  had  all  the  evi- 
dences of  acute  gonorrhoea.  If  this  patient's  veracity  were  not 
beyond  dispute,  the  etiology  of  his  attack  might  have  been 
questioned.  An  examination  of  his  discharge  showed  distinct 
gonococci  grouped  within  pus  corpuscles,  attached  to  epithelia 
and  disseminated  between  them.  The  friend  whose  sound  was 
borrowed  had  no  discharge,  but  rcmionage  of  his  urethra  proved 
that  it  contained  gonococci. 

Some  time  later  the  Cenircdhlatt  fur  KranhJieiten  der  Ham- 
und  Sexual- Or  gone  contained  a  report  made  by  the  patient  (a 
physician)  to  show  an  extraordinarily  long  period  of  incubation 
of  gonorrhoea — three  weeks.  The  manner  of  infection  is  equally 
interesting.  The  doctor  had  taken  a  specimen  of  a  fresh  gon- 
orrhoeal discharge  for  microscopic  examination.  Through  care- 
lessness he  had  soiled  his  fingers  with  the  discharge.  Being 
suddenly  seized  with  a  desire  to  urinate,  he  quickly  took  his 

1  Taylor :  The  Pathology  and  Treatment  of  Venereal  Diseases,  1895. 


10  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

penis  from  his  garments,  and  in  doing  so  communicated  some 
of  his  patient's  discharge  to  his  own  meatus.  The  result  was  a 
fully  developed  gonorrhoea. 

There  doubtless  may  be  similar  cases  of  extra-genital  infec- 
tion, still  they  are  exceedingly  rare.  At  all  events,  when  as- 
serted, it  can  do  no  harm  to  give  the  patient  the  benefit  of  the 
doubt. 

When  gonococci  have  entered  the  meatus,  they  at  once  pro- 
ceed to  proliferate  by  segmentation.  At  any  time  between 
twenty -four  hours  and  nine  or  ten  days  post  coitum,  the  lips  of 
the  meatus  are  reddened,  swollen,  and  a  watery  oozing  presents. 
This  soon  becomes  successively  whitish,  white,  whitish-yellow, 
yellowish,  yellow,  yellowish-green,  and  later  on  possibly  stained 
with  blood.  With  deepening  of  the  color  the  discharge  becomes 
more  copious  and  thick. 

The  other  symptoms  of  acute  anterior  gonorrhoea  merit  at- 
tention. White  and  Martin'  hold  that  even  preceding  the  first 
slight  puffing  of  the  meatus,  the  patient  experiences  a  constant 
desire  to  handle  and  examine  the  penis.  I  believe  that  this  is 
not  likely  to  occur  except  in  those  patients  who  have  had  gonor- 
rhoea before,  or  in  married  men  who  have  had  illicit  intercourse. 
This  direction  of  the  patient's  mind  to  his  penis  may  be  due  to 
that  "conscience  does  make  cowards  of  us  all." 

Coincident  with  or  shortly  before  the  first  slight  tumefaction 
of  the  meatus,  there  may,  however,  be  a  tickling  in  the  affected 
region.  This  is  soon  followed  by  a  sense  as  if  the  urine  were 
very  hot.  Replying  to  the  irritation  caused  by  the  increased 
number  of  the  gonococci  seeking  more  food  in  the  urethral 
mucosa,  nature  tries  to  wash  away  the  disturbance  by  increased 
urination  and  increased  secretion  of  urethral  mucus.  The  pa- 
tient, yielding  to  the  more  frequent  calls  to  urination,  experi- 
ences intense  scalding  and  cutting  pain  with  each  act.  When 
the  gonococci  have  caused  the  destruction  of  the  mucosa  in 
spots,  the  pain  on  urination  becomes  intolerable,  to  subside 
only  after  the  gonococci  have  exhausted  their  food  supply  of 
mucosa,  or  when  the  nerve  terminals  are  protected  by  tissue 
hyperplasia. 

'  WTiite  and  Martin :  Genito-Urinary  Surgery  and  Venereal  Diseases, 
Lippincott,  1898. 


ACUTE  ANTERIOR  GONORRHCEA.  11 

Coincident  with  the  irritation,  the  urethra  and  its  adjacent 
tissues  are  the  site  of  blood  afflux.  Its  results  will  be  con- 
sidered under  the  complications  of  acute  gonorrhoea. 

As  the  pains  on  urination  grow  more  severe,  the  first  50  to 
100  c.c.  (fl  3  ii.  to  fl  3  iii.)  become  turbid.  Caustic  potash 
added  to  this  urine  shows  it  to  be  laden  with  pus.  The  pain 
may,  however,  be  entirely  absent  or  may,  in  severe  cases,  con- 
tinue even  between  the  intervals  of  urination. 

This  mere  outline  of  a  sketch  of  the  development  of  a  clap 
premises  its  arrest  at  or  before  the  compressor,  i.e.,  when  it  re- 
mains an  uncomplicated  anterior  gonorrhoeal  urethritis.  That 
it  rarely  does  so  is  only  too  evident  to  physicians  who  give  the 
subject  careful  attention. 

Many  text-books  advocate  "waiting  for  the  acute  stage  to 
pass  off."  This  waiting  unfortunately  allows  the  gonococci  to 
increase,  the  infection  to  invade  the  tissues  more  deeply,  to  pro- 
ceed beyond  the  compressor,  to  develop  local  complications,  to 
involve  other  organs,  and  to  make  a  life-endangering  disease  of 
what  should  have  been  arrested  in  its  incipiency. 

So  far  as  our  present  knowledge  goes,  the  end  in  view  is  best 
attained  by  irrigations,  employed  as  early  as  possible.  How 
the  irrigations  exercise  a  beneficial  effect  may  be  subject  to  hon- 
est differences  of  opinion. 

Potassic  permanganate,  the  drug  most  frequently  employed 
for  the  purpose,  is  held  to  liberate  oxygen  in  the  tissues ;  if  the 
gonococcus  is  an  anaerobic  microbe,  it  would  die  in  the  presence 
of  oxygen.  Then  irrigations  of  hydrogen  peroxide  should  have 
a  more  prompt  effect,  which,  however,  is  disproven  in  practice. 

The  theorj'^  that  seems  most  acceptable  is  that  the  large 
volumes  of  hot  water  (110°  to  120°  F.)  employed  induce  a  species 
of  artificial  oedema  of.  the  urethra,  making  it  an  unfavorable  cul- 
ture medium  for  gonococci.  At  all  events,  it  is  nothing  rare  to 
find  the  heavy  greenish  or  bloody  discharge,  the  frightful  pains 
on  urination,  converted  into  a  mere  watery  excess  and  painless, 
normal  urination  after  one  or  two  irrigations.  Even  if  the 
course  of  the  disease  were  not  abbreviated  and  complications 
avoided  by  irrigation,  these  two  results  alone  would  justify 
ardent  advocacy  of  this  method  of  treatment. 


12  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 


III.  ANTERIOR   IRRIGATIONS. 

Irrigations  of  the  anterior  urethra  are  employed : 

1.  In  infection  of  the  anterior  urethra; 

2.  After  any  instrumentation  of  the  anterior  urethra,  whether 
for  diagnostic  or  therapeutic  purposes.  Since  making  it  an  in- 
variable rule  to  irrigate  the  uretha  even  after  urethroscopy,  I 
have  had  not  a  single  case  of  urethral  fever  to  record. 

The  technique  of  anterior  irrigations  may  be  divided  into 
preparation  of  the  patient  and  the  performance  of  the  irrigation 
itself.  Their  necessarily  detailed  description  may  make  them 
appear  complicated  and  difficult ;  their  proper  execution,  how- 
ever, is  simple  and  easy.  The  time  they  consiyne  never  ex- 
tends over  five  minutes,  even  with  a  very  sensitive  or  apprehen- 
sive patient  receiving  his  first  irrigation.  As  soon  as  the  patient 
has  learned  the  painlessness  of  a  gentle,  properly  executed  irri- 
gation and  has  experienced  the  relief  it  affords  him,  he  becomes 
the  physician's  active  coadjutor  in  further  treatment. 

Preparation  of  the  Patient. — After  the  record  of  the  case  is 
written,  a  specimen  of  the  discharge  taken  for  microscopic  ex- 
amination, and  the  urine  examined,  the  patient  is  instructed ; 

1.  To  drop  his  trousers  to  his  knees. 

2.  To  fold  his  shirt  and  undershirt  upward,  exposing  the 
abdomen. 

3.  To  sit  on  a  chair  with  a  firm,  strong  back,  in  such  a  posi- 
tion that  his  weight  does  not  rest  upon  the  tuberosities  of  the 
ischium  but  upon  the  sacrum ;  in  other  words,  he  is  placed  as 
far  forward  as  possible  upon  the  front  margin  of  the  chair. 

4.  To  rest  his  shoulders  against  the  back  of  the  chair. 

5.  To  plant  the  soles  of  his  feet  firmly  upon  the  floor. 

6.  To  direct  his  face  upward,  toward  the  ceiling.  It  is  well 
always  to  give  this  last  instruction,  lest  a  patient  with  a  malo- 
dorous breath  discover  that  an  invidious  distinction  is  made  in 
his  case.  This  position  serves  the  good  purpose  of  saving  the 
physician  the  unnecessary  disagreeable  knowledge  that  would 
otherwise  interfere  with  his  work. 

"When  the  bad  odor  of  the  breath  is  due  to  digestive  disturb- 
ance it  should  be  remedied  by  appropriate  treatment  as  quickly 


A>'TERIOR   IRRIGATIOXS. 


13 


as  possible,  so  that  no  other  condition  may  reduce  the  patient's 
resistance  to  further  invasion  of  the  gonococci. 

7.  If  the  physician  is  not  experienced  in  irrigations,  it  is 
\rell  to  protect  the  patient's  garments  with  a  large  rubber  apron, 
made  for  the  purpose  with  a  hole,  for  the  penis. 

8.  A  pan  or  bowl  of  tin  or  agate  ware  is  then  washed,  inside 
and  out,  in  hot  running  water  and  then  wiped  di-y.     It  is  well  to 


Fig.  7.— Posture  of  Patient  for  Irria^tion  in  Recumbent  Position. 


do  this  before  and  after  each  irrigation,  and  in  such  a  manner 
that  the  patient  must  observe  the  precaution ;  it  aids  in  keeping 
his  attention  fixed  upon  the  need  of  taking  every  care  against 
infection  of  others  and  of  auto-reinfection. 

9.  A  clean  towel  is  placed  upon  the  patient's  lap  and  drawn 
up  to  cover  his  testicles,  but  not  his  penis. 

10.  The  basin,  still  warm  from  its  cleansing  in  hot  water,  is 
plaxied  upon  the  towel,  and  the  patient  is  told  to  hold  it  with 
both  hands.     The  penis  is  laid  upon  the  margin  of  the  basin 


14  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

and  the  latter  slightly  tilted,  so  that  the  rim  upon  which  the 
penis  lies  encroaches  upon  the  peno-scrotal  juncture. 

Excessively  nervous  patients  may  be  inclined  to  faint  on 
merely  receiving  the  above  instructions.  It  is  well  to  irrigate 
such  patients  in  the  recumbent,  posture.  For  this  purpose  place 
a  bidet  or  irrigating  pan  upon  the  operating-table.  Draw  the 
patient's  linen  well  up  to  beyond  his  lower  ribs,  and  his  trou- 
sers and  drawers  down  to  below  his  knees.  Let  his  buttocks  rest 
far  back  on  the  pan,  to  leave  as  much  of  it  exposed  as  possible. 
Place  a  tin  bowl  between  his  knees,  tilted  with  its  concavity  up- 
ward, so  that  any  untoward  motion  on  his  part  sending  the  irri- 
gating fluid  beyond  the  shield  may  be  caught  by  the  bowl  and 
directed  into  the  pan  upon  which  he  lies.  The  irrigation  may 
then  be  made  as  easily  as  when  the  patient  is  seated,  and  with- 
out danger  of  his  fainting. 

In  very  exceptional  cases,  perhaps  once  in  a  thousand,  a  pa- 
tient is  found  who  unconsciously  responds  to  irrigations  by  a 
relaxation  of  the  compressor.  The  consequence  is  that  the  fluid 
intended  for  anterior  irrigation  enters  the  bladder.  When  a 
very  strong  solution  (such  as  potassic  permanganate,  1  :  500) 
is  used,  a  very  severe  vesical  tenesmus  at  least  is  induced  there- 
by. In  such  cases  it  is  best  to  irrigate  the  patient  in  the  stand- 
ing posture,  and  to  teach  him  to  press  his  fingers  upon  the 
perineal  portion  of  the  urethra  to  occlude  it. 

Technique  of  an  Anterior  Irrigation. — 1.  Stand  at  the  pa- 
tient's right  side. 

2.  Cleanse  the  penis,  foreskin,  glans,  and  meatus  with  cotton 
tampons  soaked  in  mercuric  bichloride,  1:3,000.  If  it  is  pre- 
ferred to  accomplish  the  cleansing  with  the  irrigating  solution ; 
then 

3.  Take  the  stopcock  in  the  right  hand  as  shown  in  Fig.  4, 
page  5,  and  for  additional  safety  pass  it  under  running  boiling 
water,  into  which  a  small  quantity  of  the  irrigating  fluid  should 
be  allowed  to  escape ;  then  close  the  flange. 

4.  Take  the  penis  in  the  left  hand,  holding  the  left  corpus 
cavernosum  by  the  third,  fourth,  and  fifth  fingers  in  such  a 
manner  that  their  tips  rest  lightly  upon  the  urethra.  The  left 
thenar  eminence,  by  being  pressed  inward,  compresses  and  al- 
most grasps  the  right  corpus  cavernosum.  The  bent  thumb  and 
index  finger  are  thus  left  free  for  manipulation  of  the  foreskin, 


ANTERIOR   IRRIGATIONS. 


15 


y^^-.^^,..^ 


glans,  and  meatus.  Tliis  manner  of  holding  the  penis  will  at  a 
first  effort  appear  to  cramp  the  hand,  but  after  two  or  three  irri- 
gations it  will  be  found  the  most  effective  and  easiest. 

5.  Gentlj  draw  the  flange  of  the  stopcock  back  by  contract- 
ing the  right  thumb  and  index  finger.  This  will  allow  a  fine 
stream  to  escape  from  the  nozzle.  Direct  this  stream  to  the 
outer  surface  of  the  foreskin  until  all  its  parts  are  thoroughly 
cleansed. 

6.  Increase  the  stream  slightly  while  directing  it  to  the 
opening  of  the  foreskin.  With  the  left  thumb  and  index  finger 
slowly  evert  the  foreskin 
and,  as  its  mucous  lin- 
ing is  thus  being  ex- 
posed, wash  each  part 
as  it  comes  into  view. 

7.  When  the  entire 
foreskin  is  retracted, 
wash  the  sulcus  behind 
the  corona,  the  glans, 
the  sulci  at  either  side 
of  the  frenum,  and  the 

lips  of  the  meatus  in  the  same  manner.  When  the  foreskin  is  so 
tight  that  it  cannot  be  everted,  drop  the  penis  and  take  up  the 
top  of  the  foreskin  with  the  left  thumb  and  index  fingers.  This 
will  leave  the  opening  of  the  foreskin  slightly  gaping.  Insert 
the  nozzle  into  the  opening  of  the  foreskin  and  increase  the  force 
of  the  stream  until  the  preputial  pouch  is  thoroughly  ballooned. 
Give  the  tip  of  the  nozzle  every  possible  direction,  so  that  the 
pouch  may  thus  be  as  effectively  cleansed  as  possible. 

8.  After  cleansing  the  foreskin,  glans,  etc.,  and  holding  the 
penis  as  shown  in  Fig.  8,  above,  contract  the  thumb  and  index 
finger  upon  the  glans,  so  as  to  open  the  meatus. 

9.  Direct  the  stream  at  first  gently  and  then  with  increasing 
force  into  the  opened  meatus,  until  all  visible  excess  of  secretion 
is  washed  from  it. 

10.  Bring  the  nozzle  closer  and  closer  to  the  meatus  until  its 
point  is  within  the  lips. 

11.  Compress  the  urethra  with  the  tips  of  the  left  third, 
fourth,  and  fifth  fingers,  to  entirely  occlude  it. 

12.  Augment  the  force  of  the  fiow  until  the  fluid  spurts  from 


Fig.  8.— Manner  of  Holding  Penis  for  Irrigation. 


16  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

the  meatus  in  such  a  manner  that  it  is  received  by  the  shield 
and  flows  from  it  into  the  basin  held  by  the  patient.  The  im- 
pact of  the  fluid  is  felt  against  the  tip  of  the  middle  finger,  where 
it  compresses  the  urethra. 

13.  When  one-fifth  of  the  contents  of  the  percolator  are  con- 
sumed in  the  irrigation  of  the  anterior  third  of  the  anterior 
urethra,  the  middle  finger  is  relaxed  and  the  fluid's  impact  is 
immediately  felt  upon  the  tip  of  the  fourth  left  finger  that  com- 
presses the  urethra. 

14.  The  same  procedure  is  successively  observed  regarding 
the  urethra  compressed  hj  the  fifth  left  finger,  and  the  impact 
of  the  fluid,  with  increased  force,  is  sent  to  the  bottom  of  the 
anterior  urethra,  i.e.,  to  the  anterior  surface  of  the  mucosa  in 
front  of  the  compressor. 

During  every  step  of  an  anterior  irrigation  enough  force 
must  be  used  to  fully  dilate  (balloon)  the  urethra.  The  nozzle 
should  never  occlude  the  meatus  entirely,  especially  when  strong 
solutions  are  used,  lest  they  be  forced  beyond  the  compressor 
into  the  bladder. 

The  division  of  the  amounts  of  fluid  used  for  each  part  of  the 
urethra  will  soon  become  so  much  a  matter  of  routine  that  the 
operator  need  not  observe  the  percolator  to  guide  him. 

After  each  irrigation  a  layer  of  absorbent  cotton  soaked  in 
mercuric  bichloride,  1:6,000,  should  be  placed  upon  the  glans 
to  receive  any  subsequent  discharge,  preventing  as  far  as  pos- 
sible auto-reinfection,  and  to  keep  the  clothing  clean.  If  the 
foreskin  is  absent  or  too  small  to  hold  the  cotton,  it  should  be 
fixed  in  place  by  means  of  a  light  gauze  bandage.  The  patient 
should  be  instructed  to  apply  a  clean  piece  of  cotton  soaked  in 
bichloride  after  each  urination. 

Some  cases  are  exceedingly  susceptible  to  the  irritant  efi'ect 
of  mercuric  bichloride,  even  a  solution  of  1:10,000  or  of  1: 
30,000  sets  up  an  inflammation  of  the  glans.  Boric  acid,  four 
per  cent.,  may  be  used  in  such  cases  to  wet  the  cotton. 

The  cotton  used  as  above  must  not  be  substituted  by  any- 
thing else.  Gonorrhoea-bags  and  condoms,  so  often  advised  for 
the  purpose,  keep  the  glans  macerated  in  pus,  not  only  inviting 
persistent  auto-reinfection,  but  also  exposing  the  glans  to  gon- 
orrhcBal  balanitis,  for  whose  existence  there  is  no  excuse. 

Some  authors  recommend  a  little  apron  made  of  linen  or 


ANTERIOR   IRRIGATIONS. 


IT 


gauze,  cut  about  two  inches  square,  with,  a  slit  in  the  centre  to 
let  the  glans  pass  through.  The  ends  of  the  apron  are  then 
folded  forward  to  cover  the  glans  and  meatus.  If  the  patient  be 
sure  to  take  off  this  apron  each  time  he  urinates  and  replace  it 
with  a  fresh  one,  its  convenience  might  make  it  advisable  to  a 
degree.  But  it  is  entirely  too  convenient  merely  to  open  the 
ends,  urinate  and  replace  the  soiled  ends  over  the  glans.  More- 
over, the  ends  are  easily  brushed  open  and  thus  the  garments 


Fig.  9.— Anterior  Irrigation,  Patient  Seated.    Towel  over  thiglis  omitted  for  clearness  of  illus- 
tration. 


are  exposed  to  being  soiled  by  the  pus.  For  these  reasons  it  is 
best  to  use  absorbent  cotton,  as  above  suggested. 

All  parts  of  an  irrigation  can,  without  any  special  dexterity, 
be  so  conducted  that  neither  the  patient's  garments,  his  person, 
nor  the  ofl&ce  floor  be  soiled.  Nothing  need  be  stained,  except 
the  operator's  left  fingers,  when  using  strong  solutions  of  jjotas- 
sic  permanganate.  They  can  be  quickly  cleaned  with  oxalic  acid 
or  sodic  bisulphide. 

As  cleanly  as  an  irrigation  should  be,  so  painless  it  is  when 
properly  carried  out.  Even  an  intensely  inflamed  urethra  ex- 
periences no  pain  if  the  operator  is  sufficiently'  gentle.  In 
this,  as  in  all  other  genito-urinary  work,  suaviter  in  modo  occu- 
pies first  place ;  fortiter  in  re  need  not  at  all  suffer  thereby. 
2  ^ 


18  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

For  this  reason  analgesia  of  the  urethra  with  cocaine  or  eucaine 
need  not  be  induced.  Moreover,  when  their  obtunding  effect 
wears  off,  the  patients  experience  more  pain  than  if  they  had 
not  been  used  at  all. 

The  time  consumed  by  irrigations  has  been  alleged  as  an  ob- 
jection to  their  employment.  A  deliberate,  properly  conducted 
anterior  irrigation  requires  about  two  minutes,  certainly  not  too 
much  time  to  devote  in  each  visit  to  so  important  a  disease  as 
anterior  gonorrhoea.  If  only  relief  from  suffering  were  obtained 
thereby,  even  ten  times  two  minutes  would  be  well  employed. 
But  the  physician,  knowing  how  dangerous  to  life  gonorrhcea  is, 
should  not  begrudge  any  amount  of  time  and  labor  directed  to 
this  end.  Even  if  the  disease  was  acquired  in  the  grossest  im- 
morality, even  if  the  patient  is  of  the  lowest,  most  degraded  type, 
it  is  unqualifiedly  the  physician's  duty  to  give  the  best  efforts 
in  order  to  prevent  the  dissemination  of  the  disease  to  others 
who  may  possibly  be  innocent  of  any  wrong. 

The  frequency  with  which  irrigations  should  be  employed 
in  acute  anterior  gonorrhea  is  set  forth  in  the  following  table. 
The  solutions  referred  to  therein  are  of  potassium  permanganate, 
— the  drug  most  frequently  used  by  all  who  emplo3^  irrigations. 
The  dilutions  are  modified  from  those  advised  in  Janet's  tables, 
which,  for  some  reason,  seem  too  strong  for  use  in  this  country. 
It  will  be  observed  that  intravesical  irrigations  appear  in  this 
table.  The  technique  of  these  will  be  described  in  Chapter  V. 
(Intravesical  Irrigations) : 

First  day,  first  visit.     Anterior  irrigation 1 :  3,000  ^   /  ^/ 

First  day,  7  p.m.  Anterior  irrigation 1 :  4,000  ^JC^jV  l< 

Second  day.  9  a.m.        Anterior  irrigation 1  :  3,000  ^y7f      / 

Second  day,  7  p.m.         Anterior  irrigation 1  :  4,000  <a^     ^ 

Third  day,  9  a.m.  Intravesical  irrigation 1 :  6,000  ,   ii^  / 

Third  day,  7  p.m.  Anterior  irrigation 1  :  5,000  V  K  • 

Fourth  day,  9  a.m.        Intravesical  irrigation 1 :  5,000 

T^       , ,    -I        „  (  Intravesical  irrigation 1 :  5,000 

Fourth  day,  7  P.M.      •]  =>  '  ^^  j 

(  Anterior  irrigation 1:2,000       o   v 

Fifth  day,  noon.  Intravesical  irrigation 1  :  5.000 

Sixtli  day,  noon.  Intravesical  irrigation 1 :  5,000 

Seventh  day,  noon.        Intravesical  irrigation 1  :  5,000 

-r-,.   ,,,    1        n  (  Intravesical  irrigation 1:5,000 

Eighth  day,  9  A.M.      -\  ^  ' 

(  Anterior  irrigation 1  :  3,000 

Intravesical  irrigation 1 :  5,000 


Eighth  day,  7  p.m. 

Anterior  irrigation 1  :  2,000 


ACUTE   POSTERIOR   GONORRHOEA.  19 

■KT-    *T,  ^        n  (  Intravesical  irrigation 1 :  4,000 

Ninth  day,  9  A.M.       ■  °  ' 

(  Anterior  irrigation 1 : 1,000 

-•T-   ^u  1        "  i  Intravesical  irrigation 1  : 4.000 

Ninth  day,  i  p.m.        -  ° 

(  Anterior  irrigation 1  :  1,000 

Tenth  day,  9  a. m.       \  Intravesical  irrigation 1  :  4,000 

(  Anterior  irrigation 1  :  1,000 

™     ,,    ,        -  (  Intravesical  irrigation 1 : 5,000 

Tenth  day,  /p.m.        -                                ° 
.    "  (  Anterior  irrigation 1  :  500 

The  hours  at  which  irrigations  are  to  be  administered  have 
been  fitted  to  the  exigencies  of  most  physicians'  office  hours. 
It  would  be  always  preferable,  however,  when  irrigations  are  to 
he  given  twice  in  one  day,  that  they  be  made  twelve  hours  apart. 


IV.  ACUTE   POSTERIOR   GONORRHOEA. 

De  Keersmaecker  and  Verhoogen'  in  brief  remarks  on  acute 
posterior  gonorrhoea,  say :  "  The  inflammation  proceeds  along 
the  whole  urethral  mucosa,  but  its  intensity  decreases  generally 
in  accord  with  its  distance  from  the  point  where  the  inoculation 
was  produced,  as  is  observed  in  every  local  infection. "  It  seems, 
however,  that  posterior  gonorrhoeal  invasion  is  an  exception 
hereto.  The  gonococci  having  traversed  the  compressor  find  a 
new  field  of  culture  in  the  posterior  urethra.  The}'  often  set  up 
an  inflammation  far  exceeding  in  virulence  that  which  affects 
the  anterior  urethra.  In  many  cases  the  patient's  sufferings 
are  not  only  materially  increased,  but,  as  Posner^  says,  "the 
portals  for  infection  of  other  organs  are  thereby  thrown  open." 

Jadassohn  holds  that  sixty  to  seventy  per  cent,  of  anterior 
gonorrhoeas  invade  the  posterior  urethra ;  Finger  places  the  ex- 
treme figure  at  eighty  per  cent. ;  while  Taylor^  claims  that  "an- 
terior urethritis  in  between  eighty  and  ninety  per  cent,  of  cases 
within  the  early  days  of  infection  passes  backward  and  involves 
the  posterior  urethra."  Close  clinical  study  of  the  question 
makes  it  appear  likely  that  even  Taylor  underestimates  the  fre- 
quency with  which  the  posterior  urethra  is  involved  in  the  dis- 


'  De  Keersmaecker  et  Verhoogen  :  L'Ur^thrite  chroniqne.  Brussels,  1898. 
■■^Posner:  Diagnostic  der  Harnkrankheiten,  Berlin,  1894. 
^  Taylor :  The  Pathology  and  Treatment  of  Venereal  Diseases,  Lea  Bros.  & 
Co.,  1895. 


20  THE   IRRIGATION   TREATMENT    OF   GONORRHCEa. 

ease.  Indeed  White  and  Martin'  say  that  the  gonococcus  "  with 
but  few  exceptions  invades  the  posterior  urethra." 

Wossidlo"  urges  that  no  apparently  cured  case  of  acute  gon- 
orrhoea be  dismissed  without  examination  of  the  prostate,  al- 
though the  posterior  urethra  does  not  seem  to  have  been  affected. 
The  absence  of  symptoms  of  posterior  urethritis  is  no  proof  that 
the  posterior  urethra  was  not  infected  by  the  gonococci  on  their 
way  to  the  adnexa. 

Causes. — Anything  that  decreases  the  vital  resistance  of  the 
posterior  urethra,  menaced  by  the  presence  of  anterior  gonor- 
rhoea, and  increases  the  intensity  of  the  latter,  is  likely  to  pro- 
duce posterior  gonorrhqea.  Among  the  most  frequent  causes  are 
neglect  of  treatment,  coitus,  irritants  applied  to  the  urethra,  alco- 
hol, fermented  or  carbonated  beverages,  and  excessive  activity. 

Time  of  Invasion. — A  neglected  or  badly  treated  anterior 
gonorrhoea  usually  invades  the  posterior  urethra  by  the  end  of 
the  first  week.  The  patient,  however,  may  perceive  no  symp- 
toms thereof  until  the  end  of  the  second  week.  A  few  days  later 
the  evidences  are  often  too  marked  to  escape  attention. 

Posterior  gonorrhoea  may,  on  the  other  hand,  become  jjain- 
fully  manifest  at  the  very  beginning  of  the  disease,  especially 
if  strong  injections,  violently  applied,  increase  the  irritation. 
This  may  convey  to  those  not  familiar  with  the  irrigation  treat- 
ment, a  condemnation  of  its  employment.  But  it  must  be  re- 
membered that  the  irrigations  applied  to  the  entire  urethra  are 
not  strong ;  moreover,  they  so  modify  the  urethral  mucosa  as  to 
make  it  an  unfavorable  culture  medium  for  gonococci.  This  in 
a  measure  explains  the  absence  of  posterior  gonorrhoea  when 
irrigations  are  properly  employed. 

Some  authors  mention  the  use  of  bougies  as  a  means  of  im- 
mediately establishing  a  posterior  gonorrhoea.  Naturally  they 
do  this  only  to  condemn  the  insertion  of  any  instrument  into  an 
acutely  inflamed  urethra.  Ipse  facto,  this  is  a  condemnation  of 
attempting  to  wash  the  urethra  with  a  catheter  or  treat  it  with 
anthrophores. 

Symptoms. — As  noted  above,  very  many  cases  of  acute  pos- 

'  White  and  Martin :  Genito-Urinary  Surgery  and  Syphilis,  Lippincott, 
1898. 

^Wossidlo:  "Chronic  Prostatitis  and  Its  Treatment."  Journal  of  the 
American  Medical  Association,  August  27th,  1898. 


ACUTE   POSTERIOE   GONORRHCEA.  21 

terior  gonorrhoea  are  insiduous  in  their  onset,  course,  and  decline. 
Most  of  these  disappear  without  any  special  treatment  being 
directed  to  the  region  infected.  Indeed  in  former  times  the 
posterior  urethra  was  deemed  one  of  the  "  sacred  regions  "  not 
to  be  entered  by  instruments  or  drugs,  and  yet  many  cases  ap- 
peared to  have  recovered.  How  many  of  these  subsided  after 
carrying  gonococci  to  the  urethral  adnexa  and  general  organism 
is  beyond  calculation.  The  hope  of  those  who  strive  to  heal 
acute  posterior  urethritis  by  treatment  of  the  anterior  urethra 
alone,  may  be  compared  with  that  of  the  gynecologist  who  en- 
deavors to  drain  pus-tubes  by  curetting,  washing,  and  draining 
the  womb.  Both  appear  to  succeed  often ;  but  as  concerns  pos- 
terior urethritis,  the  physician  would  fall  short  of  his  duty  if  he 
risked  further  complications  by  trusting  to  the  chance  that  oc- 
casionally seems  to  have  favored  the  past. 

31eclianism  of  the  Symptomatology . — In  the  insidious  form, 
the  very  slight  sufferings  or  their  absence  may  not  direct  atten- 
tion to  the  posterior  urethra.  In  the  severe  form,  nature  endeav- 
ors to  assuage  the  inflammation  by  free  secretion  of  urine.  Its 
contact  with  a  surface  rendered  exquisitely  sensitive  produces 
intense  burning.  After  the  flow  of  urine  has  ceased,  the  in- 
flamed surfaces  fall  against  each  other,  and  in  so  doing  give  the 
sensation  of  an  incompletely  accomplished  urination.  At  the 
same  time  the  folds  of  the  thickened  mucosa  squeeze  between 
them  the  delicate  nerve  terminals,  producing  the  characteristic 
after-pains.  When  somewhat  deep  denudations  have  taken  place, 
the  capillaries  may  break,  allowing  blood  to  escape,  which  may 
be  mixed  with  the  last  portion  of  the  urine,  may  follow  it  as 
clear  drops ;  or  a  distinct  stream  of  blood  may  flow,  or  the  urine 
may  carry  small  worm-like  clots,  if  blood  coagulates  in  the  pos- 
terior urethra. 

The  swelling  of  the  mucosa  and  pain  evoke  frequent,  almost 
continual  spasmodic  and  semi-voluntary  contractions  as  if  in 
effort  to  eject  the  obstructions.  This  activity  of  the  region  in- 
creases the  symptoms  as  it  augments  the  inflammation.  The 
vicious  circle  obtains  another  segment  by  each  effort  of  nature 
to  pour  out  urine.  The  latter  becomes  so  frequent  that  the 
patient  continually  strives  to  empty  his  bladder,  and  while  he 
fails  to  obtain  a  sense  of  relief,  by  acting  upon  the  desire  to  uri- 
nate, he  increases  his  pain. 


22  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

As  above  suggested,  there  is  no  exact  clironological  order  in 
wliicli  tlie  manifestations  of  acute  posterior  urethritis  follow  each 
other.  Indeed,  they  may  all  appear  to  come  on  together  with 
extreme  severity.  For  convenience  in  studying  them  a  little 
more  closely,  they  are  here  placed  in  alphabetical  order. 

Albuminuria. — When  the  urine  carries  pus,  it  accounts  for 
the  presence  of  a  proportionate  amount  of  albumin.  In  acute 
posterior  gonorrhoea,  when  vesical  tenesmus  is  at  its  highest, 
the  amount  of  albumin  carried  by  the  urine  exceeds  that  which 
would  be  expected  from  the  amount  of  pus  present.  White  and 
Martin'  deem  this  excess  "  probably  due  to  damming  back  of 
the  urine  in  the  ureters,  dependent  upon  closure  of  the  orifices 
of  these  canals  by  contraction  of  the  detrusor  muscles  of  the 
bladder ;  this  having  been  shown  to  take  place  when  tenesmus 
is  severe." 

Complications. — Proximity  and  continuity  of  mucous  surface 
render  the  prostate,  seminal  vesicles,  and  epididymides  exceed- 
ingly susceptible  to  infection  from  posterior  gonorrhoea.  The 
epithelium  covering  the  trigone,  from  its  similarity  in  character 
to  that  of  the  posterior  urethra,  is  also  liable  to  the  infection, 
but  to  a  limited  degree.  The  epithelium  lining  the  body  of  the 
bladder,  however,  seems  immune  to  gonorrhoeal  infection,  ex- 
cept when  a  pre-existent  disease  has  weakened  its  resistance, 
or  when  traumatism  has  been  exerted  upon  it,  as  by  the  abuse 
of  instruments. 

Constitutional  Symjotoms.— When  a  patient  with  gonorrhoea 
suffers  from  loss  of  appetite,  headache,  constipation,  marked 
mental  depression,  even  to  profound  neurasthenia,  and  appre- 
ciable fever,  the  physician's  attention  is  naturally  directed  to 
the  probable  invasion  of  the  posterior  urethra.  These  general 
symptoms  may  come  on  gradually  or  suddenly,  and  are  as  likely 
to  occur  in  chronic  as  in  acute  anterior  gonorrhoea.  If  given 
immediate  attention,  severe  general  suffering  and  more  danger- 
ous involvement  of  the  urethral  adnexa  may  be  averted. 

Discharge. — The  tonic  contraction  of  the  compressor  prevents 
the  discharge  of  acute  posterior  gonorrhoea  from  entering  the 
anterior  urethra.  When  it  is  so  copious  as  to  fill  the  posterior 
urethra,    the  slight,    weak    bundle   of    fibres   constituting   the 

'  Op.  cit. 


ACUTE   POSTERIOR   GONORRHCEA.  23 

sphincter  vesicae  is  more  likely  to  j-ield  to  the  pressure  and  so 
admit  the  discharge  into  the  bladder.  Even  stripping  the 
posterior  urethra  per  rectum  will  not  aid  satisfactorily  in  the 
production  of  discharge  from  the  posterior  urethra,  for  the  same 
reasons  as  given  above.  The  only  means  of  positively  reaching 
conclusions  regarding  involvement  of  the  posterior  urethra,  in 
addition  to  giving  due  heed  to  the  other  symptoms,  is  by  ex- 
amination of  the  urine  {vide  Urine  infra).  Naturally  vs^hen  the 
symptoms  appear  in  the  fulminant  type,  this  aid  to  diagnosis 
is  impossible  and  would  be  superfluous. 

Emissions. — As  abstinence  from  sexual  intercourse  is  impera- 
tive during  gonorrhoea,  for  the  patient's  sake  as  well  as  for  the 
sake  of  those  to  whom  the  disease  may  be  communicated  by 
him,  and  as  the  local  irritation  of  even  an  anterior  gonorrhoea  is 
prone  to  stimulate  increased  secretion  of  semen,  seminal  emis- 
sions are  not  infrequent.  They  occur  especiallj^  in  men  who  are 
given  to  daily  sexual  intercourse.  When,  however,  posterior 
urethritis  has  produced  hypereesthesia  of  the  caput  gallinaginis, 
the  emissions  of  semen  may  be  exceedingly  painful,  the  suffer- 
ings being  either  disseminated  through  the  perineum,  extend- 
ing up  to  the  rectum,  or  tearing  and  shooting  along  the  posterior 
urethra.  These  pains  are  often  so  intense  that  the  patient  is 
afraid  to  fall  asleep,  lest  he  be  awakened  bj^  an  emission  that 
would  evoke  their  recurrence. 

Erections. — Posterior  urethritis  is  liable  to  provoke  erections 
at  all  times,  with  or  without  erotic  incitation.  They  are  most 
frequent  when  warm  in  bed,  but  are  painless  unless  there  be 
acute  anterior  urethritis  as  well. 

Hcematuria. — Drops  of  blood,  unmixed  with  urine,  may 
escape  from  the  urethra  at  the  end  of  micturition.  This  is  usu- 
ally considered  a  positive  evidence  of  posterior  urethritis. 
While  it  most  frequently  occurs  in  this  disease,  it  may  also  be 
present  in  some  forms  of  bladder  growths  (polypus,  papilloma) 
and  stone.  When  due  to  posterior  urethritis,  the  bleeding  comes 
from  the  swollen,  congested,  and  even  eroded  mucosa.  If  the 
bleeding  is  copious  it  may  flow  into  the  bladder  and  be  mixed 
with  its  contents ;  then,  too,  some  drops  or  a  jet  of  clear  blood 
will  follow  urination.  In  such  a  case  the  urine  may  also  carry 
small,  worm-like  clots  of  blood. 

Pain. — The  pain  of  fulminant  acute  posterior  urethritis  is 


24  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

usually  most  marked  in  the  perineum.  It  is  due  to  muscular 
spasm,  provoked  by  the  tenesmus.  Its  severity  may  be  so  great 
as  to  cause  the  patient  to  act  as  if  afflicted  with  acute  mania. 
Between  the  attacks  of  intense  pain  the  patient  may  have  tick- 
ling, burning,  and  sharp  lancinations  through  the  deep  urethra, 
extending  up  the  rectum.  All  these  disturbances  are  aggravated 
by  urination  or  defecation ;  they  most  frequently  follow  the  act 
of  urination. 

Retention  of  Urine. — If  the  posterior  urethra  is  very  much 
swollen,  the  frequency  of  urination  may  suddenly  be  arrested 
and  acute  retention  take  its  place.  The  sufferings  that  before 
were  somewhat  remittent  then  become  continuous.  The  reten- 
tion may  become  quite  obstinate  from  the  increase  of  swelling 
and  reflex  tonic  contraction  of  the  sphincters.  (See  also  Com- 
plications of  Gonorrhoea :  Retention. ) 

Urination. — ^^The  slightest  quantity  of  urine  coming  into  con- 
tact with  the  inflamed  posterior  urethra  provokes  the  desire  to 
urinate.  The  patient  must  then  micturate  every  few  minutes. 
His  straining  to  pass  the  few  drops  is  accompanied  by  intense 
pain.  Although  passage  of  these  drops  gives  no  relief,  the 
patient  continues  his  efforts  to  urinate  incessantly,  being  im- 
pelled thereto  by  the  sense  of  vesical  repletion.  His  only  relief, 
when  not  treated,  is  in  the  few  moments  of  sleep  or  fainting  that 
exhaustion  brings. 

In  a  case  that  is  not  so  acute  as  the  one  described,  there 
may  be  no  painful  straining.  But  the  urination  is  frequent  and 
imperious.  The  desire  when  felt  must  be  immediately  gratified, 
otherwise  the  patient  will  urinate  into  his  trousers. 

Urine. — When  acute  disturbances  of  urination  do  not  pre- 
vent examination  of  the  urine,  and  when  the  other  symptoms  or 
conditions  direct  attention  to  the  posterior  urethra,  the  only 
method  of  reaching  a  diagnosis  is  by  examination  of  the  urine. 
Even  when  no  suspicion  guides  to  thoughts  of  posterior  urethral 
invasion,  the  urine  of  a  gonorrhoeic  should  be  examined  daily, 
so  that  the  extension  of  the  disease  may  be  met  at  its  inception. 

The  examination  should  be  made,  if  possible,  of  the  first 
urine  the  patient  passes  in  the  morning.  When  this  is  not  pos- 
sible, because  of  the  distance  at  which  the  patient  lives  from  the 
physician's  office,  the  examination  may  be  made  during  the  day, 
but  after  the  patient  has  held  his  urine  for  at  least  four  hours. 


ACUTE   POSTERIOR   GONORRHCEA.  25 

The  patient  should  be  caused  to  pass  the  first  portion,  about 
150  c.c.  (fl  3  V.)  into  a  twelve-inch  ignition  tube.'  This  washes 
the  anterior  urethra  as  clean  as  possible,  but  naturally  carries 
with  it  as  much  discharge  from  the  posterior  urethra  as  can  be 
easily  detached  from  its  walls.  The  urine  so  emitted  will  there- 
fore often  be  much  more  turbid  than  would  be  expected  from  a 
slight  discharge. 

The  second  150  c.c.  emitted  into  another  tube,  if  the  patient 
have  posterior  urethritis,  will  be  found  more  turbid  than  the 
first  portion.  Naturally  this  symptom  is  not  characteristic  if 
the  patient  have  cystitis  or  pyelitis,  or  when  a  disease  of  the 
prostate  or  seminal  vesicles  causes  their  contents  to  be  expressed 
with  the  fijial  efi^orts  of  micturition.  In  the  absence  of  these 
diseases,  and  when  the  posterior  urethra  produces  much  dis- 
charge, it  may  flow  back  into  the  bladder  and  render  its  con- 
tents turbid.  If  the  discharge  is  not  copious,  it  will  be  carried 
off  by  the  first  urine,  and  leave  the  subsequent  urine  clear. 
Both  urines,  however,  may  be  clear  when  the  jjatient  urinates 
frequently. 

-  To  cover  the  possibility  of  error  in  these  cases,  practitioners 
are  ordinarily  advised  to  wash  out  the  anterior  urethra  by  means 
of  a  soft  catheter  before  allowing  the  patient  to  urinate.  The 
greater  ease  and  safety  by  which  the  urethra  can  be  cleansed  by 
means  of  anterior  irrigations  make  the  latter  method  preferable. 
By  carefully  exercising  the  technique  of  anterior  irrigations  (see 
page  12),  and  using  warm  boric-acid  solution  for  the  purpose, 
the  anterior  urethra  can  be  quickly  freed  from  any  discharge  it 
may  at  the  time  harbor.  "WTien  the  solution  that  spurts  from 
the  meatus  is  entirely  clear  of  even  fine  granules,  the  patient 
should  immediately  urinate  into  two  tubes.  If  the  first  tube 
contains  pus  and  the  second  does  not,  the  diagnosis  of  posterior 
urethritis  is  established  wdth  a  fair  degree  of  accurac3^ 

A  better  and  not  much  more  circumstantial  test,  especially 
applicable  when  the  urine  is  not  turbid,  can  be  made  by  add- 
ing to  the  boric  acid  used  for  irrigation  a  quantity  of  methylene 
blue  representing  one  per  cent,  of  its  quantity  (twenty-four  grains 

^  These  twelve-inch  ignition  tubes  are  erroneously  called  "Valentine's  urine 
tubes  "by  dealers.  I  did  nothing  but  suggest  the  convenience  of  these  tubes 
for  macroscopic  examination,  comparison,  and  chemical  and  microscopical 
investigations  of  lu-ine. 


26  THE   IRRIGATION   TREATMENT    OF   GONORRHOEA. 

to  the  quart) .  If  tlie  urine  passed  into  the  first  tube  contains 
shreds,  filaments,  flakes,  or  granules  which  the  microscope  shows 
to  be  stained  blue,  it  would  tend  to  prove  that  they  come  from 
the  anterior  urethra.  If  they  are  not  stained  by  the  irrigation, 
their  source  is  the  posterior  urethra. 

The  need  of  careful  study  and  early  treatment  of  posterior 
urethritis  is  evident,  despite  the  fact  that  many  of  the  cases 
appear  to  recover  without  treatment.  Their  tendency  is  to  go 
over  into  a  subacute  or  chronic  state,  to  produce  recurrent  gon- 
orrhoea, and  to  evoke  a  long  list  of  neuroses  which  are  often  in- 
effectually treated  until  the  source  of  the  evil  is  ascertained. 

Treatment. — As  is  quite  natural,  the  treatment  of  acute  pos- 
terior urethritis  must  vary  in  accord  with  the  form  in  which  it 
appears.  If  its  onset  is  in  the  most  insidious  manner,  so  that 
its  presence  is  determined  only  by  examination  of  the  urine,  the 
safest,  quickest,  and  easiest  method  of  cutting  it  short  is  by 
intravesical  irrigations,  whose  technique  is  fully  detailed  on 
page  29. 

These  intravesical  irrigations  may  be  performed  once  daily, 
beginning  with  potassium  permanganate  solution  of  1 : 6,000;  on 
the  second  day  the  strength  of  the  solution  may  be  increased 
to  1:5,000;  on  the  third  day  1:4,000  may  be  used  and  if  no 
reaction  result,  a  further  increase  to  1 :  3,000  maj'  be  employed 
on  the  fourth  and  subsequent  days.  Some  patients'  bladders 
will  very  comfortably  bear  much  stronger  solutions. 

If  in  five  or  sis  days  the  urine  does  not  indicate  complete 
subsidence  of  the  posterior  urethritis,  mercuric  bichloride  may 
be  added  to  the  jjotassic  permanganate  solution  last  emploj^ed. 
The  addition  of  the  bichloride  should  at  first  not  be  stronger 
than  1 :  50,000.  On  the  second  day  this  may  be  made  1  :  40,000; 
on  the  third  day  1 :  30,000 ;  on  the  fourth  day  1 :  25,000.  Only 
in  very  persistent  cases  can  1 :  20,000  be  employed. 

Some  cases  do  better  with  the  bichloride  alone  and  in  the 
solutions  above  indicated. 

Occasionally  a  case  will  be  found  in  which  neither  the  per- 
manganate nor  the  bichloride  nor  both  in  combination  yield 
prompt  effects.  Then  silver  nitrate  may  be  employed  in  solu- 
tions of  1 : 5,000,  1 : 4,000,  1 : 3,000,  or  1 : 2,500,  using  the  mildest 
on  the  first  day  and  daily  increasing  the  strength,  but  not  beyond 
1:2,500. 


ACUTE   POSTERIOR   GONORRHCEA.  27 

These  irrigations,  when  properly  conducted,  are  borne  ex- 
ceedingly well  by  patients ;  they  experience  an  almost  immediate 
relief  fi'om  the  slight  subjective  or  reflex  symptoms  due  to  the 
iDsidious  form  of  the  disease  under  discussion. 

When  acute  posterior  gonorrhoea  asserts  itself  in  the  fulmi- 
nant form,  the  prime  indication  is  to  break  the  before-described 
vicious  circle  at  some  point.  As  in  all  acute  inflammations, 
rest  of  the  affected  region  must  be  sought. 

Patients  so  affected  should  be  kept  in  bed  and  on  a  diet  of 
little  else  than  skimmed  milk.  Mild  laxatives,  that  keep  the 
rectum  clear  and  deplete  the  jjelvic  viscera,  must  be  persistently 
given. 

The  one  drug  that  gives  signal  relief  in  hyperacute  cases  is 
santal  oil.  As  was  shown  by  investigations  made  in  Berlin  in 
1894  and  1895,  santal  oil  caimot  be  expected  to  act  as  a  gono- 
coccicide.'  It  does,  however,  prove  a  decided  analgesic  of  the 
urinary  apparatus,  and  especially  its  lower  part.  To  procure 
its  effect  as  quickly  as  possible,  it  may  be  given  in  ten  minim 
doses  every  two  hours  for  six  or  eight  hours.  As  soon  as  the 
tenesmus  begins  to  subside  and  the  bleeding  after  urination 
materially  decreases,  the  inteiwals  should  be  increased  to  four, 
five,  or  six  hours,  until  pain  has  entirely  disappeared.  As  this 
drug  is  prone  to  evoke  renal  irritation,  it  should  be  withdraum 
as  soon  as  the  indications  for  its  use  have  subsided. 

The  teas  (infusions)  of  uva  ursi  leaves,  hemiaria,  chenopo- 
dium,  triticum  rejjens,  etc.,  which  were  formerly  highly  lauded 
for  their  presumed  efl'ects  in  such  cases,  have  proven  ineff^ective 
in  my  hands.  They  only  augment  diuresis,  and  in  doing  so  in- 
crease the  activity  of  the  inflamed  parts,  that  should  be  kejjt  at 
rest.  Salicylate  of  sodium  and  salol,  which  often  show  such  fa- 
vorable results  in  cystitis,  jjiove  utterly  inactive  in  acute  poste- 
rior urethritis. 

When  the  attack  is  so  severe  that  the  eft'ect  of  santal  oil  can- 
not be  awaited,  then  morphine  gr.  ^  -  i,  especially  in  supposi- 
tories, will  afford  quick  relief.  'WTien  this  does  not  act  piromptly 
iodoform,  gr.  +,  may  be  added  to  the  suppository.  Belladonna 
has  yielded  no  results  to  me  in  doses  that  are  safely  adminis- 
tered.    At  the  same  time  that  the  suppositories  and  santal  oil 

'  Valentine  :  "Der  Einflu-ss  der  Balsamicis,  insbesondere  des  Santalols  auf 
Gonococcen."     Pick's  Archiv.  April,  1895. 


28 


THE    IRRIGATION    TREATMENT    OF    GONORRHCEA. 


are  used,  local  depletion  may  be  hastened  by  the 
application  of  four  to  six  leeches  to  the  peri- 
neum. 

It  is  generally  held  that  when  acute  gonor- 
rhcea  suddenly  invades  the  posterior  urethra, 
direct  treatment  of  the  anterior  urethra  is  contra- 
indicated.  Comparison  of  the  results  of  this 
neglect  of  treatment  with  those  obtained  by  con- 
tinuing local  treatment  show  to  the  decided  ad- 
vantage of  the  latter.  Therefore  irrigations  must 
be  continued.  If  the  patient  is  too  weak  to  have 
them  administered  in  the  sitting  posture,  he  may 
receive  them  while  lying  in  bed.  To  facilitate 
such  irrigations  a  sewing-board  or  leaf  of  an  ex- 
tension table  may  be  pushed  under  that  part  of 
the  mattress  beneath  the  patient's  buttocks.  With 
ordinary  care,  irrigations  can  then  be  performed 
without  even  moistening  the  bed-clothes. 

It  is  more  particularly  in  the  exceedingly  severe 
cases  which  persist  despite  all  the  treatment  above 
described  that  intravesical  irrigations  of  potassium 
permanganate  give  prompt  relief.  The  hot  (110° 
to  120°  r.)  antiseptic  solutions,  ver}^  gentlj^  ad- 
ministered, seem  to  act  as  a  soothing  poultice  to 
the  inflamed,  eroded  posterior  urethra.  It  is  not 
rare  to  see  a  patient  after  such  an  irrigation  fall 
asleep  and  rest  comfortably  for  several  hours,  to 
awake  much  relieved. 

Guyon  uses  several  drops  of  a  one  to  two  per 
cent,  silver  nitrate  solution  instilled  into  the  pos- 
terior urethra.     While  the  relief  so  obtained  can- 
not be  denied,  the  local  reaction  that  follows  is 
frequently  very  severe.      This  may  be  limited  by 
precedent  appreciable  doses  of  morphine,  by  pre- 
liminary instillation  of  a  few  drops  of  cocaine  if 
one  is  sure  that  the  patient  is  not  too  susceptible 
to  its  toxic  effects,  or  by  giving  the  patient  a  quarter  of  a  tea- 
spoonful  of  sodic  bicarbonate  (Kobner)  thirty  minutes  before 
making  the  instillation. 

If,  for  any  reason,  irrigations  cannot  be  employed,  Guj'on'a 


POSTERIOR   OR   INTRAVESICAL   IRRIGATIONS.  29 

instillations  may  be  used  every  two  or  three  days.  The  severe 
pains  they  produce  can  be  very  materially  reduced,  and  often 
entirely  avoided,  if  Guyon's  technique  be  closely  followed. 

The  instrument  found  best  for  the  purpose  is  Albarran's 
modification  of  Guyon's  instillator.  It  consists  of  a  syringe,  a 
little  larger  than  the  ordinary  hypodermic  syringe,  with  a  rod 
passing  through  the  piston,  by  means  of  which  the  packing  can 
be  rendered  tight  or  loose  at  will.  A  tightly  fitting  metal  funnel 
serves  to  connect  the  syringe  with  a  rubber  capillary  catheter 
shaped  like  a  bougie  a  boule,  and  soft  enough  to  be  easily  in- 
serted. Each  complete  turn  of  the  handle  deposits  a  drop  of 
the  solution  in  the  posterior  urethra.  If  the  deposits  are  made 
by  quarter  turns,  and  consequently  by  quarter  drops,  with  an 
interval  of  ten  to  twenty  seconds  between  each  application,  the 
pain  will  be  minimized,  larger  quantities  can  be  introduced,  and 
a  quicker  effect  obtained  (Guy on). 


V.    TECHNiaUE  OF  POSTERIOR  OR  INTRA- 
VESICAL  IRRIGATIONS. 

Keeping  in  mind  how  feeble  a  bundle  of  muscular  fibres 
constitute  the  sphincter  vesicae,  it  is  evident  that  anj^  appreciable 
quantity  of  fluid  carried  into  the  posterior  urethra  through  the 
strong  compressor  must  enter  the  bladder.  Hence  irrigation 
of  the  posterior  urethra  distinctly  implies  irrigation  of  the 
bladder  at  the  same  time.  For  convenience,  therefore,  irriga- 
tions of  the  posterior  urethra  are  called  intravesical  irriga- 
tions. 

Preparation  of  the  Patient. — The  patient  is  prepared  and  sits, 
stands,  or  lies  down,  as  may  be  necessary,  under  the  rules  de- 
tailed on  page  12. 

The  Irrigation. — 1.  Perform  thoroughly  all  the  steps  de- 
scribed under  Anterior  Irrigation  (page  16),  using  only  half  the 
quantities  of  fluid  there  mentioned. 

2.  Hold  the  penis  firmly,  while  gently  sinking  the  nozzle 
into  the  meatus,  until  it  is  entirely  occluded  thereby.  At  the 
same  time  slowly  increase  the  force  of  the  flow,  by  drawing  back 
the  flange  of  the  stopcock. 

3.  As  the  urethra  is  felt  distending  under  the  left  flnger  tips, 


30 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


order  tlie  patient  to  breathe  deeph'  and  slowly,  and  to  make 
efforts  at  urination. 

4.  Ordinarily  wlien  the  third  step  of  this  operation  is  being 
performed,  a  sensation  of  purling  of  the  liquid,  as  it  enters  the 
bladder,  will  be  communicated  to  the  left  fingers. 

5.  After  one-half  or  three-quarters  of  a  minute  the  inflow  will 
become  less  accentuated  and  slower,  as  the  bladder  is  being  filled. 


Fig.  11.— HoldlBg  Basin  and  Stopcock  and  Handing  Urinal  to  Patient. 


Then  slowly  push  forward  the  flange  of  the  stopcock,  to  dimin- 
ish the  force  of  the  flow,  until  it  is  stopped.  By  close  observ- 
ance of  this  technique,  the  bladder  can  be  entirely  filled  without 
producing  pain  or  even  an  urgent  desire  to  urinate. 

6.  Rest  the  penis  on  the  margin  of  the  basin,  leaving  the  left 
hand  free. 

7.  Place  the  stopcock  in  the  basin;  pass  the  right  thumb 
through  its  large  ring ;  pass  the  right  fingers  to  the  outside  of 
the  basin  to  hold  it  firmly  with  the  stopcock. 

8.  Extend  the  left  hand  to  the  shelf  on  which  the  glass 
urinals  are  kept  (one  may  also  conveniently  stand  under  the 
patient's  chair),  take  one  and  hand  it  to  the  patient. 

9.  Order  the  patient  to  take  his  penis  with  his  left  hand  and 
to  direct  it  toward  the  urinal,  which  he  holds  in  his  right. 

10.  Take  the  basin  and  stopcock  from  the  patient's  lap. 


POSTERIOR   OR   INTRAVESICAL   IRRIGATIONS.  31 

11.  Order  tlie  patient  to  void  his  bladder  into  the  urinal; 
some  can  do  this  sitting,  others  must  rise  for  the  purpose. 

12.  While  the  patient  is  emptying  his  bladder,  pour  the 
contents  of  the  basin  into  the  sink  and  wash  out  the  basin  with 
warm  water,  if  the  patient  is  to  be  immediately  irrigated  again. 
If  not,  wash  the  basin  with  boiling  water,  and  place  it  with  the 
used  basins,  to  be  thoroughly-  cleansed  after  office  hours. 

13.  Without  removing  the  used  nozzle  from  the  stopcock, 
hold  both  under  running,  boiling  water  for  a  few  moments. 
Then  remove  the  nozzle  and  place  it  in  a  dish  kept  for  used 
nozzles  and  containing  mercuric  bichloride  1:1,000.  After 
office  hours  boil  the  used  nozzles  in  water  and  caustic  soda; 
rinse  them  in  clean  water  and  place  them  in  a  dish  containing 
mercuric  bichloride  1 : 1,000. 

All  the  steps  of  intravesical  irrigation,  like  those  of  anterior 
irrigation,  can  be  effectively,  thoroughly,  and  painlessly  per- 
formed without  soiling  any  x^art  of  the  patient's  person  or  body, 
or  of  the  office. 

Amount  Bequired  for  Filling  the  Bladder. — The  average  male 
bladder  can  comfortably  hold  about  350  c.c.  (nearly  fl  5  xiss.); 
variations  between  250  and  500  c.c.  are,  however,  within  the 
limits  of  health. 

Bepetition  of  an  Intravesical  Irrigation. — Ordinarily'  after  one 
irrigation  the  glass  urinal  shows  its  contents  to  be  as  clear  as 
when  the  fluid  was  sent  into  the  bladder.  When  this  is  not  the 
case,  the  irrigation  may  at  once  be  repeated. 

ImiJedhnents  to  Irrigation. — In  some  cases,  when  for  anj- 
reason  the  preparations  for  irrigation  are  somewhat  prolonged, 
or  when  the  patient  is  nervous,  there  may  be  a  somewhat  free 
outpouring  of  urine  from  the  kidneys,  after  the  patient  has 
emptied  his  bladder.  A  small  quantity  of  urine  in  this  viscus 
may  set  up  such  a  spasm  of  the  compressor  that  when  an  intra- 
vesical irrigation  is  attempted  it  cannot  be  overcome  by  the 
pressure  of  the  irrigating  fluid.  Such  a  patient  should  be 
ordered  to  again  empty  his  bladder ;  the  irrigation  will  then  be 
quite  easily  performed. 

When  potassic  permanganate  is  used  in  a  case  in  which  some 
urine  is  withheld,  it  will  be  returned  from  the  bladder  either 
turbid  or  of  a  light  straw  or  brownish  hue.  A  second  irrigation 
will  then  produce  as  clear  a  fluid  as  was  used. 


32  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


Fig.  13.— Office  Arrangement.  A,  Author's  urethral  and  intravesical  irrigator ;  upper  margin 
of  board  attai-hed  to  wall  nine  feet  from  floor ;  B,  stand  eighteen  inches  high ;  C,  marble 
wash-stand  (constructed  by  Mr.  John  H.  Graham  of  New  York);  D,  hot-water  pedal ;  E,  cold- 
water  pedal ;  F,  outflow  trap ;  G,  mortar  for  rapidly  making  potassic  permanganate  solu- 
tions from  tablets :  H,  glass  urinal ;  i,  bottle  containing  potassic  permanganate  tablets,  3 
grains  each;  J,  glass  graduate  1,500  c.c.  to  measure  urine;    F,  tray  holding  clean  urine 


POSTERIOR   OR   INTRAVESICAL   IRRIGATIONS.  33 

Some  patients,  in  making  violent  respiratory  efforts,  coupled 
with  endeavors  to  urinate  during  irrigation,  will  force  the  com 
pressor  into  a  firm  tonic  spasm.  It  is  well,  in  such  cases,  to 
ask  the  patient  to  desist  from  his  efforts,  and,  while  reducing  the 
hydrostatic  pressure,  to  divert  his  attention  from  the  matter  in 
hand.  This  is  best  accomplished  by  some  witticism ;  not,  how- 
ever, one  of  which  the  patient  is  the  object.  The  slightest  ten- 
dency of  the  patient  to  laugh  is  instantly  accompanied  by  a 
relaxation  of  the  compressor  and  a  consequent  inflow  of  the 
irrigation  fluid  into  the  bladder. 

Office  Arrangement. — In  a  large  genito-urinary  practice  much 
time  can  be  gained  and  convenience  secured  by  an  office  arrange- 
ment as  shown  in  Fig.  12,  page  32.  It  will  be  observed  that  the 
patient's  chair  stands  on  a  platform.  This  is  eighteen  inches 
high,  which  is  equivalent  to  irrigating  the  patient  when  the 
chair  is  on  the  floor  and  the  irrigator  raised  only  seven  and 
one-half  instead  of  nine  feet  from  the  floor.  This  reduction  of 
pressure  will  make  no  difference  to  the  physician  experienced 
in  irrigations.  Moreover,  the  platform  will  prove  very  con- 
venient, when  many  irrigations  must  be  done  during  the  day, 
as  it  saves  the  physician  much  stooping. 

Physicians  who  are  obliged  to  irrigate  only  a  few  patients 
daily  do  not  need  the  somewhat  expensive  office  arrangements 
here  shown.  They  can  do  fully  as  effective  and  satisfactory 
work  without. 

Further  points  concerning  irrigations  will  be  discussed 
under  the  conditions  to  which  they  especially  apply. 


tubes ;  K,  small  glass  graduate  to  make  solutions  of  silver  nitrate,  cupric  sulphate,  etc. ;  K^, 
glass  dishes  holding  sterilized  nozzles  in  bichloride  1 : 1,000 ;  i,  glass  tray  containing  used 
nozzles ;  iV/,  tray  to  hold  used  instruments ;  ISf,X.X,X,  solutions  of  silver  nitrate  ,  0.  minim 
graduate ;  P,  bottle  containing  powdered  boric  acid ;  other  bottles  on  this  shelf  contain  car- 
bolic acid,  nitric  acid,  etc. ;-  q,  bottle  holding  three  gallons  boric  acid,  four-per-cent.  solu- 
tion ;  R,  flve-gallon  bottle  containing  mercuric  bichloride  1 :  l,iJ<X)  Cq  and  R  have  rubber 
tubes  pending  from  them):  .?.  Bernstein  Company's  oflQce  table;  T,  irrigating  basins ;  U, 
glass  urinal ;  TF,  pan  for  irrigation  in  recumbent  posture. 

3 


34  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


VI.    CONSTITUTIONAL  AND  ACCESSORY 
TREATMENT. 

Any  conduct,  food,  or  drink  that  increases  the  irritation  of 
the  inflamed  region  or  regions  in  gonorrhoea  must,  as  in  inflam- 
mations of  other  parts,  necessarilj^  increase  the  disease,  prolong 
its  duration,  and  thwart  the  ultimate  object  of  treatment. 

There  is  little  difficulty  in  causing  patients  to  submit  to  the 
necessary  restrictions  when  they  are  made  aware  of  the  risks 
incurred  by  their  infraction  (see  Chapter  VII.  "  Complications  ") . 
The  constitutional  and  accessory  treatment  entails  some  restric- 
tions, which  will  be  indicated  here. 

Amusements. — The  depressing  influence  which  clap  exercises 
upon  most  minds  may  be  due  to  the  consciousness  of  being 
affected  with  an  unclean  disease,  to  the  deprivation  of  sexual 
intercourse,  and  to  enforced  abstinence  from  alcohol.  This,  how- 
ever, would  not  account  for  the  depression  so  frequent  in  those 
who  do  not  allow  the  presence  of  a  clap,  unless  accompanied 
by  painful  symptoms,  to  interfere  with  their  self -gratifications. 
The  possible  effect  of  gonococci  toxins  directly  upon  the  nervous 
system  may,  when  better  understood,  give  the  explanation. 

If  a  patient  with  gonorrhoea  were  to  withdraw  from  all  enter- 
tainments during  the  disease,  he  would  necessarily  brood  over 
the  cause  of  his  ostracism  and  its  consequences.  This  would 
accentuate  the  mental  depression.  He  should  therefore  seek 
diversion,  such  as  society,  theatres,  etc.,  offer,  but  most  posi- 
tively avoid  people,  scenes,  exhibitions,  and  literature  that  could 
evoke  lubricious  thoughts. 

Bathing. — ^There  is  no  reason,  during  gonorrhoea,  for  absti- 
nence from  the  daily  bath ;  on  the  contrary,  it  is  necessary  for 
the  purpose  of  maintaining  the  patient' is  resistance.  But  sev- 
eral precautions  in  bathing  are  absolutely  imperative.  Before 
bathing,  the  patient  should  urinate,  dress  the  glans  with  cotton 
soaked  in  mercuric  bichloride  1 : 6,000,  or  boric  acid  four  per 
cent. ,  and  cover  the  entire  penis  with  a  well-fitting  condom,  to 
be  worn  throughout  the  bath.  This  is  the  only  safe  manner  in 
which  gonorrhoeal  pus  can  be  prevented  from  mixing  with  the 
bathing  water  and  possibly  adhering  to  the  sides  of  the  tub, 


CONSTITUTIONAL   AND    ACCESSORY    TREATMENT.  35 

"witli  all  the  danger  to  the  eyes  of  the  patient,  and  to  the  eyes, 
vagina,  or  rectum  of  another  who  may  use  the  bath-tub  after  him. 
While  no  one,  even  in  health,  will  rely  upon  the  care  of  servants 
to  cleanse  a  bath  after  he  used  it,  the  gonorrhoeic  must  be  spe- 
cially cautious  in  this  regard.  It  would  never  be  an  excess  of 
conscientiousness  if  the  patient  scrubbed  the  entire  bath-tub 
personally  with  brush  and  strong  soap,  using  boiling  water  into 
which  he  has  dissolved  two  ounces  of  corrosive  sublimate,  for  a 
tub  capacity  of  twenty-five  gallons.  Following  this,  the  hot 
water  should  be  allowed  to  run  again  until  the  tub  is  entirely 
filled,,  to  rinse  it  after  the  scrubbing.  Even  those  who  live  in 
bachelor  apartments  and  have  their  individual  baths  should  be 
instructed  to  do  this  for  self-protection. 

After  the  bath  the  condom  should  be  removed  at  once,  and 
thrown  into  the  water-closet  or  preferably  burned. 

Bed. — The  gonorrhoeic  patient  should  sleep  on  a  hard  mat- 
tress with  light  coverings,  lest  the  heat  of  either  provoke  erec- 
tions, with  their  determination  of  blood  to  the  inflamed  region, 
and  possibility  of  chordee.  As  erections  are  not  likely  to  occur 
while  the  patient  sleeps  on  his  side,  it  will  be  well  if  he  ties  a 
towel  around  his  abdomen  with  a  hard  knot  immediately  over 
the  spine.  Should  he  turn  on  to  his  back  during  sleep,  the  pres- 
sure of  the  knot  will  either  awake  him  or  cause  him  to  return  to 
his  side  without  disturbing  his  sleep. 

Beverages. — With  a  view  to  diluting  the  urine  so  that  it  may 
prove  less  irritating  to  the  urethra,  diuretics  and  diluents  of 
all  kinds  are  advised.  The  only  diluent  of  any  value  is  pure 
water  in  very  large  quantities,  as  a  gobletful  (fl  3  vi.)  every  two 
hours  or  every  hour. 

All  alcoholic  beverages  must  be  strictly  interdicted,  unless 
the  patient  is  in  the  habit  of  using  them  to  such  an  extent  that 
his  appetite  would  suffer  from  the  deprivation.  Then  a  glass, 
or  even  two,  of  light  claret  may  be  allowed  at  meals.  But  beer, 
white  wine,  champagne,  whiskey,  and  brandy  must  be  positively 
forbidden. 

Carbonated  drinks,  such  as  vichy,  seltzer,  ginger  ale,  sarsa- 
parilla,  soda  water,  and  other  beverages  charged  with  carbonic 
acid  gas,  are  much  used  by  patients  with  gonorrhoea,  under  the 
prevailing  impression  that  they  are  beneficent  in  the  disease. 
This  is  a  signal  error,  as  all  these  drinks  are  genito-urinary 


36  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

irritants.  The  extent  to  which  the  damage  caused  hy  carbonated 
drinks  can  go  is  well  shown  in  a  case  reported  to  the  Deutsche 
medicinische  Gesellschaft  by  its  president,  Dr.  H.  G.  Klotz,  on 
March  6th,  1899.  The  patient,  aged  twenty-two,  had  been 
treated  for  gonorrhoea  and  stricture.  Suddenly  a  white  lump, 
resembling  macerated  chalk  ("  geschlemmte  Kreide  ")  and  some 
blood  were  ejected  from  the  urethra,  amidst  violent  pains  radi- 
ating from  the  renal  region.  For  some  days  the  urine  was 
heavily  turbid  and  contained  albumin.  Chemically  and  micro- 
scopically phosphates  were  found,  and  the  sediment  contained 
various  cocci  and  epithelial  cells.  The  author  assumes  that 
phosi^hates  had  accumulated  in  and  irritated  the  renal  pelvis 
and  calices  in  consequence  of  the  patient's  drinking  large  quantities 
of  carbonated  soda.  The  author  shows  that  an  accumulation  per 
se  so  innocent  as  that  of  phosphates  can  produce  -inflammation 
of  the  kidney,  if  improperly  treated  or  neglected  Such  an 
acute  nephritis  can  as  readily  proceed  to  chronic  nephritis  as 
can  the  renal  inflammations  due  to  other  causes. 

Klotz  relied  mainly  upon  urotropin  in  this  case,  which  was 
cured  in  the  course  of  three  weeks. 

This  and  many  cases  with  a  similar  history  may  account  for 
the  large  number  of  kidneys  invaded  and  destroyed  by  gono- 
cocci,  if  they  were  perfectly  healthy  before  the  patient  was  the 
victim  of  clap. 

"Drinking  away  a  Clap." — Many  patients  assure  their  phy- 
sician that  they  have  known  men  with  very  acute  gonorrhoea  to 
drink  heavily  for  a  long  time  and  thus  cause  the  clap  to  disap- 
pear. Some  will  relate  this  as  a  personal  experience  in  a  pre- 
vious attack.  This  statement  deserves  all  the  allowance  phy- 
sicians must  make  for  the  curious  ideas  that  in  some  manner 
have  forced  themselves  upon  the  laity.  The  fact  remains  that 
the  patient  who  alleges  that  he  "  drank  Sbway  "  a  previous  clap, 
or  honestly  thinks  he  knows  of  others  who  performed  this  im- 
possible feat,  is  then  under  treatment  and  continues  under  it 
until  he  is  well.  Meanwhile  he  abstains  from  fantastic  efforts 
to  cure  the  disease  with  alcohol  in  any  form. 

Exercise. — Unless  the  patient  has  fever,  he  should  take 
sufficient  exercise  to  keep  himself  in  good  condition.     Walking, 

'Klotz:  "Phosphatarie  and  Pyelo- Nephritis."  New  Yorker  medicinische 
Monatschrift,  October,  1899. 


CONSTITUTIONAL   AND   ACCESSORY   TREATMENT.  37 

driving  over  smootli  roads,  rowing,  and  such  outdoor  sports  as 
will  give  him  gentle  exercise  are  certainly  recommendable,  not 
only  for  their  physical  but  also  for  their  mental  effect. 

Bicycling  and  horseback  eidtng  must  be  positively  forbid- 
den during  gonorrhoea,  as  they  expose  the  testicles  and  pros- 
tate to  vibration  at  least,  or  small  concussions,  if  not  severe 
injury,  inviting  extension  of  the  disease  to  these  organs - 

In  this  connection  Prof.  G   Frank  Lydston  says. 

"Cycling  frequently  produces  hyperactivity  of  the  sexual 
organs  with  resulting  disposition  to  sexual  excess  and  aggrava- 
tion of  any.  pathological  condition  which  may  be  present  .  . 
urethral  and  prostatic  inflammation  are  often  aggravated  by 
bicycle  riding.  Relapses  of  inflammatory-  troubles  of  the  ure- 
thra, prostate,  and  bladder  very  often  follow  bicj^  cling.  I  doubt 
whether  inflammation  may  be  produced  de  novo  in  individuals 
possessing  a  previously  healthy  genito-urinary  apparatus.  An 
exception  might  possibly  be  made  in  the  case  of  individuals  who 
ride  that  peculiar  form  of  bicycle  invented  by  the  devil  and 
dedicated  to  Eros  —the  bicycle  built  for  two." 

Food. — If  a  patient  with  gonorrhoea  has  not  a  disturbing 
elevation  of  temperature,  he  certainly  requires  sufiicient  food  to 
keep  him  as  well  nourished  as  possible,  to  aid  him  in  resisting 
the  microbic  invasion.  In  this  quest  all  articles  difiicult  of 
digestion  must  be  avoided,  as  must  all  food  that  for  any  reason 
disagrees  with  the  patient. 

Some  authors  hold  that  if  a  patient  with  gonorrhoea  were 
kept  in  bed  on  a  very  low  diet,  he  would  recover  from  the  infec- 
tion without  local  treatment.  I  regret  that  I  must  confess  hav- 
ing made  the  experiment,  which  each  time  resulted  in  abject 
failure. 

While  complete  rest  in  bed  and  low  diet  are  absolutely  neces- 
sary in  the  severe  form  of  posterior  gonorrhoea,  they  are  useless 
without  proper  medication  (see  Chapter  IV. ,  "  Acute  Posterior 
Gonorrhoea"). 

When  acute  gonorrhoea  is  not  accompanied  by  much  eleva- 
tion of  temperature,  and  when  no  comx)lication  obliges  the  pa- 
tient to  remain  in  bed,  this,  together  with  reducing  his  food, 


'Lydston:  "Athletics  in  their  Relation  to  the  Male  Genito-Urinary  Or- 
gans."   Medical  Mirror,  St.  Louis,  September,  1899. 


38  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

would  supply  means  for  reducing  Ins  resistance  to  the  microbic 
invasion. 

Gin  is  mentioned  separately  because  of  the  wide  reputation 
it  unjustly  enjoys  for  beneficial  effects  in  gonorrhoea.  While  it 
acts  as  a  diuretic,  it  irritates  the  kidney  directly  and  the  rest  of 
the  genito-urinary  apparatus  as  much  or  even  more  than  an^^ 
other  alcoholic  beverage. 

Suspensory  Bandages. — Their  necessity  in  gonorrhoea  is 
discussed  under  Epididymitis,  page  55. 

Tobacco. — It  is  not  shown  at  all  that  smoking  or  chewing 
tobacco  exerts  any  unfavorable  or  favorable  influence  upon  gon- 
orrhoea, unless  the  patient  uses  tobacco  to  a  depressing  extent. 
Then,  naturally,  its  use  must  be  curtailed. 


VII.    COMPLICATIONS  AND   SEaUEL-ffi   OF 
GONORRHCEA. 

An  acute  gonorrhoea,  if  treated  by  properly  conducted  irriga- 
tions from  the  inception  of  the  disease,  does  not  become  com- 
plicated. But  patients  with  a  first  gonorrhoea,  or  those  who 
have  never  been  treated  by  irrigations,  are  not  likely  to  come 
for  treatment  early,  i.e.,  when  the  first  swelling  of  the  lij^s  of 
the  meatus  presents,  or  shortly  thereafter.  Others,  in  whom 
irrigations  have  not  been  judiciously  employed,  may  present 
complications.  A  final  and  very  large  class  embraces  those 
men  who  had  gonorrhoeas  before  and,  having  been  improperly 
treated,  acquired  conditions  (strictures  inter  alia)  which  com- 
plicate the  newly  acquired  disease. 

When  urethral  complications  existed  before  the  new  gonor- 
rhoea, they  cannot  be  diagnosed  until  the  acute  symptoms  have 
been  subjugated  by  irrigations,  as  the  insertion  of  an  instru- 
ment into  an  acutely  inflamed  urethra  is  never  warranted.  The 
only  exception  hereto  ma,j  be  in  acute  retention,  when  all  other 
means  have  failed,  and  catheterization  remains  the  sole  refuge 
for  emptjdng  the  bladder. 

For  convenient  reference,  the  most  frequent  complications  of 
gonorrhoea  are  here  placed  in  alphabetical  order. 

Abscess,  Follicidar  and  Peri-urethral. — If  the  gonococci  lim- 
ited their  search  for  pabulum  to  the  surface  of  the  urethra,  their 


COMPLICATIONS   AND   SEQUEL JE   OF   GONORRHCEA.  39 

progress,  and  that  of  the  inflammation  they  produce,  would  ex- 
tend only  backward.  But  they  also  invade  the  mucous  follicles 
and  gland  ducts.  When  this  occurs,  as  it  very  frequently  does, 
the  finger  passed  along  the  lower  surface  of  the  urethra  when 
exposed  as  for  anterior  irrigation  (vide  ante,  Fig.  8,  page  15) 
finds  distinct  nodulations.  The  glands  and  follicles  are  espe- 
cially well  developed  at  the  meatus,  whence  pus  may  be  easily 
expressed. 

When  swelling  or  inflammatory  exudation  occludes  the  ducts, 
the  normal  or  catarrhal  secretion  of  their  glands  is  retained. 
The  resultant  pus  pockets  (follicular  abscesses)  are  thus  ex- 
plained. As  the  follicles  are  ordinarily  most  numerous  in  the 
anterior  third  of  the  pendulous  portion,  this  is  the  most  frequent 
site  of  these  abscesses.  They  soon  become  distended  with  pus 
and  then  feel  like  shot  of  various  sizes  under  the  skin,  which 
is  normal  in  color  and  freely  movable  over  the  abscesses. 
Touching  them  sometimes  causes  quite  sharp  pain.  While  in 
this  condition,  the  probability  is  that  they  will  open  into  the 
urethra.  When  the  abscesses  terminate  in  this  manner,  the 
ducts  that  have  been  occluded  become  patulous  again. 

When  the  follicular  abscess  does  not  terminate  as  just  de- 
scribed, the  skin  over  it  becomes  red  and  attached  to  the  nodule. 
If  not  relieved  by  early  incision  it  breaks  down  and  the  pus 
cavity  is  evacuated  externally.  The  duct  of  the  gland  so  de- 
stroyed is  obliterated,  and  the  abscess  cavity  heals  by  granula- 
tion. 

Sometimes  quite  an  agglomeration  of  such  follicular  abscesses 
presents  near  the  attachment  of  the  frenum  to  the  meatus.  The 
frenum  is  then  apt  to  become  very  oedematous,  entirely  obliter- 
ating the  normal  depressions  at  its  sides.  The  angry  appear- 
ance of  the  region  conveys  the  impression  that  the  abscess  must 
destroy  or  at  least  perforate  the  frenum  or  result  in  fistula. 
But  after  discharge  of  the  pus,  the  abscesses  ordinarily  heal, 
the  oedema  subsides,  and  the  ducts  of  the  follicles  remain  closed ; 
consequently  neither  fistula  nor  destruction  of  the  frenum  re- 
sults. As,  however,  either  outcome  is  possible,  the  unaided 
breaking  of  these  abscesses  should  not  be  awaited. 

A  gummatous  nodulation  at  the  base  of  the  frenum,  usually 
painless,  may  be  mistaken  for  follicular  abscess,  especially  if 
the  patient  has  forgotten,  as  sometimes  in  reality  happens,  that 


•iO  THE  IRRIGATION   TREATMENT   OF   GONORRHCEA, 

he  ever  liad  syphilis.  If  the  tumor  is  gummatous,  vigorous 
antiseptic  dressings  are  decidedly  contraindicated.  Incision 
could  produce  only  breaking  down  of  the  gumma,  insuring  per- 
haps large  destruction  of  the  penis.  Therefore  when  such  a 
gumma  presents,  nothing  but  mild  antiseptic  dressings  should 
he  employed,  while  remedial  measures  are  administered  con- 
stitutionally. 

As  the  mucous  follicles  at  the  frenum  are  walled  bj^  rather 
dense  fibrous  tissue,  their  abscess  formation  is  circumscribed. 
Yet  from  any  cause  this  fibrous  envelope  may  give  way  and  pro- 
duce extensive  destruction  and  deformity  of  the  glans.  There- 
fore surgical  intervention,  as  early  as  possible,  is  a  wise  and 
necessary  i3recaution.  Failure  to  employ  it  has  occasionally 
been  followed  by  such  cicatricial  contractions  as  to  so  distort 
the  relation  of  the  glans  to  the  penis  as  to  make  erection  ex- 
ceedinglj^  painful  and  coitus  impossible. 

The  follicles  at  other  parts  of  the  urethra  than  those  near 
the  frenum  have  less  connective-tissue  protection.  Therefore 
when  they  become  involved  their  disease  products  are  prone  to 
invade  the  tissue  of  the  corpora  cavernosa  penis  and  still  more 
the  corpus  cavernosum  urethrse.  Suppuration  of  the  follicles 
here  takes  on  the  form  of  peri -urethral  abscess. 

These  abscesses  around  the  urethra  originate  as  folliculitis 
or  adenitis.  Their  pain,  tenderness,  and  swelling  are  greater 
and  develop  more  rapidly.  If  the  swelling  urethra  ward  is  more 
marked,  the  urinary  stream  is  smaller  than  normal.  Some- 
times, when  the  pain  is  greatest,  the  duct  proves  to  be  the  point 
of  least  resistance.  It  will  then  suddenly  give  way  and  permit 
the  pus  to  escape  into  the  urethra.  The  pain  then  is  arrested 
or  very  much  mitigated,  the  tension  about  the  swelling  is  re- 
duced, and  the  urine  carries  with  it  pus  and  blood.  If  the  ab- 
scess cavity  points  forward,  i.e.,  toward  the  meatus,  it  will 
probably  heal  rapidly.  If,  however,  it  has  not  this  direction, 
urine  may  enter  it  and  urinary  infiltration  with  all  its  dangers 
may  result,  requiring  rapid,  free  incision.  Should  the  abscess 
open  both  within  the  urethra  and  through  the  skin,  urinary 
fistula  is  the  consequence. 

When  a  peri-urethral  abscess  first  presents,  gentle  massage 
may  cause  its  contents  to  overcome  the  swelling  of  the  duct  and 
restore  its  patulousness.     When  this  fails,  the  enlarged  glands 


COMPLICATIONS   AND    SEQUEL.^    OF   GOXORRHGEA.  41 

or  follicles  should  be  slit,  curetted,  and  dressed  "witli  nosopjlieu. 
The  large  amount  of  pus  that  then  escapes  seems  utterly  out  of 
proportion  to  the  size  of  the  tumor.  When  the  swelling  is  dif- 
fuse or  painful,  enveloping  the  penis  in  hot  or  cold  antiseptic 
dressings  may  give  relief. 

While  it  is  true  that  many  peri-urethral  abscesses  open  spon- 
taneously, it  is  not  well  to  rely  upon  this  outcome ;  it  is  likely 
to  result  in  an  open  sinus  or  fistula.  When  such  spontaneous 
opening  has  occurred,  jjermanent  catheterization  should  be  em- 
ployed as  a  safeguard  against  urinary  infiltration. 

If  unhealed  follicular  or  peri-urethral  abscess  precedes  an 
acute  gonorrhoea,  the  dangers  and  difficulties  of  cure  are  very 
much  enhanced.  '^ 

Adenitis  (gonorrho^al) — see  Lymphadenitis. 

Adhesions  (prepufial)  are  often  practically  congenital.  At 
all  events  many  children  sent  to  the  specialist  for  circumcision 
are  found  to  have  the  prepuce  more  or  less  firmly  adherent  to 
the  glans.  Concretions  of  smegma  may  harden  and  cause  ulcer- 
ation of  the  delicate  mucosa ;  drops  of  urine  may  be  retained  in 
the  preputial  sac,  decompose  and  irritate  the  tissues,  and  uri- 
nary salts  may  form  calculi  there.  The  constitutional  conse- 
quences of  adherent  prepuce  and  the  other  conditions  mentioned 
are  well  described  by  pediatrists. 

When  an  adult  with  adherent  prepuce  acquires  gonorrhoea 
the  case  is  practically  incurable,  unless  the  prepuce  is  immedi- 
ately detached  from  the  glans.  This  is  easily  done  with  a  stout, 
blunt  probe,  after  injecting  a  four-per-cent.  solution  of  cocaine 
into  as  much  of  the  sac  as  can  be  reached  by  it.  While  the 
denudations  so  produced  may  threaten  invasion  of  the  organism, 
especially  if  the  gonorrhoea  depends  upon  a  mixed  infection, 
the  chance  of  danger  is  far  less  than  if  the  disease  is  allowed  to 
continue  because  of  the  adhesions.  After  sejiarating  the  pre- 
puce, readherence  of  the  raw  surface  will  be  prevented  by  dress- 
ing the  glans  with  absorbent  cotton  soaked  in  mercuric  bichlo- 
ride, as  described  on  page  16.  When  the  orifice  of  the  foreskin 
is  too  tight  for  the  admission  of  cotton,  reformed  adhesions 
should  be  broken  up  by  passing  the  sterilized  probe  entirely 
about  the  glans,  beneath  the  prepuce,  before  each  irrigation. 
The  lesions  produced  by  this  little  operation  ordinarily  heal 
in  about  forty-eight  hours,  leaving  a  freely  movable  foreskin. 


42  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Notwithstanding  the  favorable  result,  such  patients  should  be 
circumcised  as  soon  as  they  have  recovered  from  gonorrhoea. 

When  preputial  adhesions  result  from  gonorrhoeal  balano- 
posthitis,  they  should  be  treated  as  above  outlined.  As  then 
the  inflammatory  process  has  usually  much  thickened  the  fore- 
skin, greater  gentleness  in  the  operation,  if  possible,  is  required. 
It  may  be  well,  in  such  a  case,  to  keep  the  penis  continually 
soaked  for  a  day  or  two  in  hot  bichloride  solution  1 :  10,000  that 
the  swelling  may  subside  before  separating  the  jDrepuce  from  the 
glans.  In  extreme  cases  it  may  be  wise  to  remove  the  foreskin 
entirely  if  the  above-mentioned  measures  cannot  bo  carried  out. 

Stripping  the  prepuce  beyond  the  glans  to  break  up  adhe- 
sions is  exceedingly  painful,  unsurgical,  and  uuuecessarih^  pro- 
longs the  treatment.  Moreover,  it  exposes  the  patient  to  the 
dangers  of  paraphimosis. 

Albuminuria. — The  urine  of  a  gonorrhoeic  always  contains 
albumin  as  part  of  the  pus  it  carries.  When  vesical  tenesmus 
accompanies  the  disease,  the  urine  shows  more  albumin  than 
is  accountable  by  the  amount  of  pus  present.  The  explanation 
of  this  excess  of  albumin  that  seems  most  reasonable  has  been 
mentioned  on  page  22.  The  treatment  for  this  mechanical  al- 
buminuria is  touched  upon  under  vesical  tenesmus  (page  27). 

Anemia. — ^Whon  anaemia  complicates  a  gonorrhoea,  the  pa- 
tient's vital  resistance  is  reduced,  the  case  prolonged,  and  inva- 
sion of  other  organs  invited.  Such  a  condition  must  be  met  by 
the  approjjriate  constitutional  remedies,  in  addition  to  irriga- 
tions. 

Balanitis  and  Balanoposthitis. — "Though  gonococci  seem 
to  play  no  causative  role  in  the  production  of  balanitis,  or  in- 
flammation of  the  surface  of  the  glans  penis,  this  is  a  frequent 
complication  of  gonorrhoea"  (White  and  Martin).  On  the  other 
hand  balanitis,  so  frequently  produced  by  uncleanliness,  phi- 
mosis, or  adhesions  of  the  prepuce,  may  extend  to  the  urethra 
evoking  a  discharge  therefrom  which  symptomatically  resembles 
gonorrhoea.  The  absence  of  gonococci  from  this  discharge  may 
prove  the  urethritis  to  be  due  to  an  infection  from  the  balanitis. 

Most  frequently,  predisposition  to  inflammation  of  the 
mucous  lining  of  the  glans  and  foreskin  is  brought  about  by  a 
very  large  or  very  dense  or  tight  prepuce,  or  one  with  a  small 
opening.      The  normal   secretions   are  then  retained   causing 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  43 

epithelial  softening,  and  the  apposed  surfaces  rub  upon  each 
other,  producing  denudations.  When  contagious  material  enters 
the  preputial  sac,  it  finds  at  least  some  of  the  region  without  its 
uppermost  epithelial  protection  and  therefore  a  good  culture 
medium. 

Rheumatism,  gout,  and  diabetes  also  predispose  the  patient 
to  balanoposthitis. 

Traumatisms,  even  so  slight  as  friction  from  the  clothing, 
violent  attempts  at  intercourse,  and  contact  with  irritating  dis- 
charges may  also  cause  balanoposthitis. 

Heat,  some  tickling  or  itching  about  the  glans,  provoking 
frequent  erections,  inaugurate  inflammation  of  the  mucous  cover- 
ing of  the  glans  or  lining  of  the  foreskin.  This  is  usually  asso- 
ciated with  or  quickly  followed  by  redness  and  swelling  of  the 
preputial  orifice.  A  little  later  a  foul-smelling  discharge,  if  not 
so  copious  as  to  escape  unaided,  can  be  pressed  out  of  the 
orifice.  If  the  prepuce  can  be  stripped  back,  a  thick,  paste- 
like, irregularly  lumpy  secretion,  mixed  with  liquid  pus  of  a 
very  putrid  odor,  is  discovered.  When  the  inflammation  has 
existed  some  days,  the  mucous  membrane  of  the  glans  may  be 
eroded,  occasionally  iu  circular  or  irregular  spots,  grossly  re- 
sembling chancre  or  chancroid. 

,If  neglected,  the  inflammation  of  the  preputial  sac  is  likely 
to  cause  immense  swelling  of  the  foreskin  and  glans.  The 
oedema  of  the  foreskin  may  go  over  into  an  erysipelatous  red- 
dening, which  may  extend  to  the  root  of  the  penis.  The  lymph 
ducts  may  be  involved.  Inflammatory  phimosis  or  paraphimosis 
may  result.  The  pressure  then  exercised  by  the  prepuce  and  the 
glans  upon  one  another  may  produce  gangrene  of  either  or  both. 

Even  if  such  extreme  results  do  not  obtain,  balanoposthitis 
may  cause  adhesions  of  the  prepuce  to  the  glans,  rendering 
erection  painful  and  coitus  impossible. 

The  first  indication  for  treatment  of  balanitis  and  balano- 
posthitis is  naturally  in  the  removal  of  the  cause.  When  the 
foreskin  can  be  everted,  the  sac  must  be  gently  but  thoroughly 
cleansed  with  cotton  tampons  soaked  in  hot  bichloride  solution 
1 : 3,000  or  1 : 4,000.  Then  nosophen  is  thinlj^  strewn  upon  the 
exposed  mucosa.  A  thin  layer  of  absorbent  cotton  is  placed 
about  the  glans,  and  the  foreskin  drawn  into  place  again.  Ac- 
cording to  the  severity  of  the  case  this  may  be  repeated  twice 


44 


THE   IRRIGATION   TREATMENT   OP   GONORRHCEA. 


or  three  times  daily .  Light  cases,  that  seemed  inveterate  under 
other  treatment,  yield  to  the  one  just  described  very  quickly, 
sometimes  as  soon  as  within  forty-eight  hours. 

When  the  disease  has  proceeded  to  such  swelling  of  the  pre- 
puce that  it  cannot  be  retracted  or  when  it  aflfects  the  sac  of  a 
tight  or  partially  adherent  prepuce,  irrigations  of  the  sac  with 
potassic  permanganate  1 : 2,000  or  1 : 3,000,  twice  or  three  times 
daily,  will  cause  the  inflammation  to  abate. 

When  the  prepuce  is  cedematous  and  very  tender  to  the  touch, 
the  penis  may  be  kept  continuously  wrapped  in  a  hot  bichloride 


Fig.  13.— Taylor's  Phimosis  Scissors. 


solution  1 :  10,000  until  the  swelling  subsides  sufficiently  for 
more  direct  treatment, 

"When  the  inguinal  glands  are  enlarged  in  the  presence  of  a 
very  intense  swelling  of  the  foreskin,  through  which  an  indura- 
tion is  felt,  the  surgeon  may  be  justified  in  splitting  the  prepuce 
to  expose  and  treat  a  possible  phagedenic  ulcer,  which,  if  neg- 
lected, may  destroy  the  glans  or  a  great  part  of  the  penis. 

Under  such  circumstances,  or  when  the  j^atient  is  a  diabetic, 
it  is  usual  to  slit  the  dorsal  aspect  of  the  prepuce,  with  a  view 
to  complete  circumcision,  after  the  acute  inflammatory  condi- 
tion has  passed  off.  But  this  slitting,  especially  when  the  swell- 
ing and  induration  are  great,  does  not  expose  the  glans  and 
the  lining  of  the  prepuce  nearly  as  much  as  would  be  desirable. 
Therefore  it  is  much  better  and  more  effective  to  cut  both  sides 
of  the  foreskin  midway  between  the  dorsum  and  the  frenum,  as 
proposed  by  Taylor.  The  scissors  he  devised  for  the  purpose 
will  be  found  the  best  instrument  that  can  be  used.  When  these 
scissors  are  not  at  hand  they  can  be  substituted  by  a  grooved 
director  to  protect  the  glans  and  guide  a  stout  curved  bistoury 
to  the  coronary  sulcus. 


COMPLICATIONS   AND   SEQUEL.^    OF   GONORRHCEA.  45 

The  clanger  of  infecting  the  so  cut  surfaces  must  be  accepted 
as  the  risk  preferable  to  the  one  of  allowing  the  penis  to  be  de- 
stroyed by  an  unknown  ulcer. 

Immediate  circumcision  would  be  more  desirable,  but  the 
incision  that  then  encircles  the  penis  would  not  be  likely  to 
unite  by  primary  union.  Even  if  general  infection  does  not 
result,  circumcision  in  such  cases  is  prone  to  be  followed  by 
extensive  sloughing,  from  whose  destructive  results  the  thermo- 
cautery even  maj^  not  save  the  penis. 

Later  on,  when  the  primary  condition  has  subsided,  com- 
plete circumcision  may  be  advantageously  performed  for  cos- 
metic effect. 

Bladdee,  Inflammation  of — see  Cystitis. 

Bleeding— see  Hemorrhage. 

"Blind"  fistul.e,  i.e.,  minute  canals  having  their  opening 
posteriorly  from  the  meatus,  may  cause  a  gonorrhcea  to  be  ex- 
ceedingly obstinate.  If  the  inflammatory  condition  does  not 
i:)roduce  their  obliteration,  or  if  irrigations  do  not  produce  in 
them  that  general  oedema  which  would  make  them  an  unfavor- 
able culture  medium  for  gonococci,  they  continue  to  supply  in- 
fection to  the  urethra.  They  may,  in  part,  account  for  the  five 
per  cent,  of  failures  in  the  irrigation  treatment  as  collated  by 
Goldberg  (page  1). 

In  obstinate  cases  they  should  be  sought  by  means  of  the 
urethroscope  and  silver  nitrate  injected  into  them  by  Kollmann's 
syringe ;  this  failing  the}-  must  be  slit  into  the  urethra  or  extir- 
pated. When  such  a  fistula  is  very  shallow  and  close  to  the 
meatus,  it  can  usually  be  destroyed  by  electrolysis,  performed 
under  cocaine  anaesthesia. 

Bubo — -see  Lymphadenitis. 

Cavernitis  may  complicate  a  very  mild  gonorrhoea,  when 
the  urethral  epithelial  layer  is  subject  to  traumatism,  admitting 
gonococci  to  the  mucosa  itself,  to  the  submucous  tissues,  and 
through  these  to  the  corpora  cavernosa  penis  or  corpus  caver- 
nosum  urethrse.  The  traumatisms  doing  this  damage  may  be 
strong  injections  destroying  the  epithelium,  misuse  of  a  sharp- 
pointed  syringe,  clumsiness  in  use  of  sharp  irrigation  nozzles, 
antrophores,  sounds,  or  catheters.  Violence  in  irrigations,  per- 
formed by  people  who  mistook  their  vocation  when  they  en- 
tered the  profession  of  Medicine,   may  cause   rupture  of  the 


46  THE    IRRIGATION   TREATMENT    OF    GONORRHCEA. 

superficial  layers  of  tlie  urethral  mucosa,  with  a  consequent 
cavernitis. 

In  the  beginning  of  cavernitis  the  slight  swelling  may  escape 
notice  except  during  erection.  Then,  as  the  infiltration  does 
not  expand  with  the  rest  of  the  organ,  it  is  bent  or  twisted 
toward  the  affected  side.  If  the  corpus  cavernosum  urethras  is 
affected,  the  penis  is  bent  in  the  bow-form,  familiarly  called 
cliordee  (q.  v.  hifra). 

If  the  invasion  of  the  corpora  cavernosa  does  not  end  in  reso- 
lution, permanent  infiltration  or  abscess  forms.  In  the  former 
case  local  circulation  may  be  seriously  impeded,  with  possibly 
consequent  atrophy  of  the  surrounding  tissues.  This  may  so 
deflect  the  penis  during  erection  as  to  render  coitus  impossible. 

In  the  beginning  of  cavernitis  rest,  persistent  hot  or  cold 
antiseptic  applications,  leeches  to  the  perineum,  low  diet,  pur- 
gatives, camphor  or  its  monobromate,  with  or  without  opium, 
will  give  relief  and  aid  resorption.  In  hyperacute  cases,  in 
which  relief  is  not  obtained  by  the  above-mentioned  measures, 
the  infiltration  may  be  punctured  with  fine  needles  to  allow  some 
blood  to  escape.  The  most  exquisitely  employed  aseptic  pre- 
cautions must  be  observed  in  this  operation,  which,  as  has  been 
suggested  above,  is  in  place  only  as  a  last  resort.  In  five  cases 
so  treated  immediate  relief  was  obtained.  One  retained  a  slight 
contraction  of  the  right  corpus  cavernosum,  not  enough,  how- 
ever, to  interfere  with  coitus.     The  others  recovered  entirely. 

In  chronic  cases  galvanism,  several  times  a  week,  one  pole 
applied  to  the  infiltration  and  the  other  to  the  opposite  portion 
of  the  penis,  may  stimulate  resorption. 

Sometimes  general  infiltration  affects  the  three  corpora  cav- 
ernosa equally,  producing  persistent  but  painless  priapism. 
One  patient  treated  for  subsequent  stricture  said  that  for  three 
weeks  he  had  been  so  affected ;  all  remedial  efforts  proved  un- 
availing. He  was  sent  on  a  sea  voyage,  and  on  the  first  day  the 
erection  subsided.  As  the  physician  who  had  treated  this  case 
had  died,  the  exact  facts  could  not  be  obtained. 

Oberlaender'  cites  a  case  of  cavernitis  reported  by  Kollmann 
-which  differs  very  much  from  those  generally  described.     Im- 

'  Oberlaender :  "Die  chronischen  Erkraiikungen  der  mannlichen  Harn- 
rohre."    Klinisches  Handbuch  der  Hani-  und  Sexual-Organe,  Leipzig,  1894. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  47 

mediately  after  the  excision  of  a  primary  chancre  on.  the  pre- 
puce, preceded  by  an  injection  of  cocaine,  a  small  infiltration 
behind  the  glans  appeared.  It  grew  to  the  size  of  a  bean,  and 
as  it  became  larger,  it  travelled  several  centimetres  toward  the 
scrotum  in  the  course  of  a  few  months.  Then  it  proceeded  for- 
ward again,  dividing  into  two  parts.  When  so  situated  erections 
were  disturbed ;  once  the  penis  was  doubled  into  a  decided  right 
angle.  Later  on  the  infiltrate  travelled  to  the  peno-scrotal  junc- 
ture, where  it  remained  and  became  smaller,  but  could  be  dis- 
tinctly palpated  four  and  one-half  years  after  its  first  appearance. 
Gonorrhoea  could  never  be  proven  in  this  case ;  nor  could  this 
cavernitis  be  attributable  to  syphilis,  as  it  was  not  affected  by 
antisyphilitic  treatment.  The  excision  of  the  chancre  did  not 
prevent  general  infection. 

Chancroid,  or  chancre,  or  a  mixed  sore,  may  complicate  gon- 
orrhoea. But  even  if  either  involves  the  meatus  or  the  urethra, 
careful  irrigations  need  not  be  omitted. 

Chordee,  Chorda  Venerea. — Da  Costa,'  in  his  admirable 
chapter  on  "Diseases  of  the  Genito-urinary  Organs,"  defines 
chordee  as  "  a  condition  of  painful  erection  in  which  the  penis 
is  markedly  bent."  The  patients  describe  it  as  the  sensation  of 
a  hot  wire  drawn  through  the  penis,  like  the  cord  of  a  bow. 
This  bending  is  naturally  in  the  direction  of  that  part  of  the 
penis  which  is  rendered  less  elastic  and  therefore  cannot  take 
part  in  the  general  turgescence  of  erection.  When  the  inflam- 
matory action  penetrates  the  submucous  tissues  and  from  them 
into  the  trabeculae  of  the  corpus  spongiosum,  its  extensibility  is 
naturally  impaired.  Keflex  irritability  provokes  frequent  erec- 
tions, and  as  the  inflamed  corpus  spongiosum  cannot  swell  and 
stretch  with  the  rest  of  the  organ,  the  penis  is  bent.  In  the 
bending  intense  pain  is  produced.  The  lymph  exudation  that 
follows  this  inflammatory  condition  fills  the  intratrabecular 
spaces,  preventing  their  filling  with  blood  during  erection. 

The  pain  may  become  so  intense  that  the  patient  in  his  des- 
peration may  recall  having  heard  of  "breaking  the  chordee." 
This  is  accomplished  by  laying  the  penis  on  a  flat  surface,  such 
as  that  of  a  table,  and  striking  the  curved  organ  with  the  fist  or 
a  book.     One  patient  reported  that  he  placed  his  penis  on  a  win- 

'  Da  Costa  :  A  Manual  of  Modern  Surgery,  Saunders,  Philadelphia,  1898. 


48  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

dow  ledge  and  violently  pulled  down  the  sash  upon  it.  White 
and  Martin  {op.  cit.,  p.  96)  say  that  "at  times  patients  have 
sought  relief  by  intercourse.  The  results  are  nearly  as  disas- 
trous as  those  consequent  on  forcible  breaking,  at  least  one 
death  being  attributable  thereto." 

Naturally,  no  physician  would  advocate  the  brutal  violence 
above  mentioned.  It  may  cause  laceration  of  the  urethra,  with 
possibly  fatal  haemorrhage,  rupture,  with  extravasation  of  urine 
and  death  from  urinary  infection,  laceration  of  the  corpora  cav- 
ernosa, and  gangrene  of  the  penis.  Even  if  none  of  these  super- 
vene and  if  no  very  heavy  stricture  result,  the  part  of  the  penis 
anterior  to  the  site  of  the  infiltration  may  be  cut  off  from  enough 
blood  supply  to  produce  erection  therein. 

In  chordee,  the  treatment  outlined  under  cavernitis  may 
suffice.  In  very  severe  cases,  persistently  continued  very  hot 
sitz  baths  may  be  added.  If  these  fail,  it  may  be  necessary  to 
use  opium  or  any  of  its  derivatives  to  its  full  effect. 

Condylomata. — The  fact  that  condylomata  usually  appear 
upon  the  genitals  probably  accounts  for  their  being  called  vene- 
real warts.  No  proof,  however,  exists  that  they  are  due  to  vene- 
real infection.  As  they  originate  most  frequently  upon  moist 
surfaces,  such  as  the  mucous  membranes  of  parts  of  the  male 
and  female  genitalia,  the  Germans  call  them  Feuclitwarzen  (moist 
warts) .  Through  careless  mispronunciation  this  easily  becomes 
'' Feigwarzen,''  whose  translation  "fig  warts"  has  in  some  man- 
ner invaded  the  English  language.  It  would  require  more  than 
ordinary  imagination  to  conceive  any  resemblance  to  fresh  or 
dried  figs  in  these  warts,  except  perhaps  when  the  latter  have 
grown  very  large  and  their  upper  surface  exposed  to  the  air 
presents  a  dry,  horny  yellowish-brown  color,  with  rough  nodu- 
lar surfaces. 

Weichselbaum  described  a  condylomatous  excrescence  as  a 
"simple  or  branched  papilla,  built  on  the  type  of  a  skin  or 
mucous  papilla,  and  covered  with  epithelium  of  varying  thick- 
ness. The  connective  tissue  in  these  papillae  is  generally  much 
richer  in  cells  and  vessels  than  is  the  connective  tissue  of  the 
base  from  which  they  spring.  The  epithelial  covering  can  be 
materially  thicker  than  that  of  the  region  from  which  it  origi- 
nates, but  ordinarily  it  has  the  usual  character  of  the  epithe- 
lium of  the  region.     The  papillomata  proceed  from  the  normal 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA,  49 

papillae  of  the  skin  or  mucosa,  wliicli  enlarge ;  new  formation  of 
papillae  also  takes  place." 

These  moist  or  dry  papillary  overgrowths  may  be  as  small 
as  pin  points,  or  may  reach  almost  any  size.  They  may  be 
discrete  or  confluent.  They  begin  in  the  sulci  at  either  side  of 
the  frenum  and  in  the  sulcus  behind  the  corona  with  equal  fre- 
quency. They  less  frequently  originate  on  the  posterior  border 
of  the  glans,  the  orifice  of  the  foreskin,  and  least  frequentl3r 
upon  the  lips  of  the  meatus.  They  rarely  appear  within  the 
urethra. 

Irritating  discharges  either  of  gonorrhoea  or  the  disturbance 
set  up  by  uncleanliness,  secretion  retained  and  decomposed  by 
a  redundant  or  tight  foreskin  may  cause  these  warts.  Accord- 
ing to  their  growth,  which  often  is  very  rapid,  and  according  to 
whether  or  not  they  are  compressed  between  foreskin  and  glans, 
they  may  assume  a  shape  and  color  varying  from  those  of  a  moist 
red  raspberry  to  those  of  a  yellowish- white  cauliflower.  They 
may  also  by  pressure  of  the  foreskin  form  long  ridges  "  like  a 
cock's  comb"  (White  and  Martin). 

When  flat  and  macerated  by  free  secretion  or  discharge,  con- 
dylomata may  be  mistaken  for  mucous  patches.  When  broad- 
ened by  growth,  they  may  suggest  syphilitic  warts.  But  when 
lues  exists,  the  excrescences  on  the  penis  are  not  usually  its 
only  evidence,  even  if  a  history  of  syphilis  is  denied. 

A  wart  appearing  on  the  penis  after  middle  life  should  al- 
ways suggest  the  possibility  of  epithelioma,  even  if  its  sur- 
rounding tissues  are  not  infiltrated  and  the  inguinal  glands  not 
indurated.  The  presumed  wart  should  at  once  be  thoroughly 
extirpated  and  microscopically  examined  for  purposes  of  prog- 
nosis. 

When  condylomata  proliferate  upon  the  glans  they  may  in- 
duce pressure  gangrene  of  the  foreskin.  After  the  gangrenous 
part  of  the  x^repuce  is  cast  off,  the  whole  or  part  of  the  condylo- 
mata may  prolapse  through  the  space  so  produced.  When  warts 
grow  upon  the  meatus  they  may  interfere  with  urination  and 
ejaculation. 

As  uncleanliness  and  maceration  of  their  seat  are  the  cause 
of  condylomata,  so  scrupulous  cleanliness  and  dryness  are  the 
prime  indications  for  treatment  while  they  are  still  small,  i.e., 
when  thev  are  but  little  more  than  hyaline  spots. 
4 


50  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

When  they  are  isolated  and  take  on  tlie  accuminate  form, 
cleansing,  drying,  and  dusting  with  powdered  savin  acts  as  a 
direct  specific. '  But  even  when  they  are  quite  large,  powdered 
savin  is  worth  trying  for  a  few  days.  It  occasionally  causes  the 
warts  to  slough  off  with  surprising  rapidity,  leaving  a  base  that 
heals  very  soon. 

If  the  mass  is  large  and  heavy,  it  may  be  touched  three 
times  daily  with  ferric  chloride.  The  surfaces  so  treated  shrink. 
The  shrivelled  portions  may  be  curetted  and  the  application 
repeated.  By  successive  scrapings  and  applications  of  ferric 
chloride  the  base  is  eventually  reached.  This  must  be  thor- 
oughly curetted  and  its  bleeding  arrested  with  cotton  pledgets 
soaked  in  five-per-cent.  solution  of  antipyrin. 

Exceedingly  large  and  confluent  warts  may  require  removal 
by  the  knife.  The  base  may  then  be  curetted  and  cauterized,  or 
after  curetting,  the  wound  edges  brought  together  by  sutures. 
Usually  the  bleeding  is  very  copious.  If  it  cannot  be  other- 
wise controlled  it  must  be  arrested  by  the  actual  cautery. 

Intra-urethral  papillomata,  when  they  do  not  materially  re- 
duce the  urethral  calibre,  can  be  removed  through  the  urethro- 
scopic  tube.  When  their  number  and  size  prevent  introduction 
of  the  tube,  the  first  growth  may  be  grasped  through  a  meato- 
scope  by  means  of  a  silk  thread.  This  serves  to  draw  the  ure- 
thral mucosa  gently  forward  sufficiently  to  expose  the  deeper 
growths,  which  then  can  be  removed  by  ligature  or  the  incan- 
descent snare. 

CowPERiTis  is  of  relatively  infrequent  occurrence.  It  may  be 
due  to  aggravating  an  acute  or  chronic  gonorrhoea  by  sexual 
intercourse,  undue  exercise,  an  untoward  motion,  or  alcohol,  by 
unskilled  catheterization  {i.e.,  traumatism  from  within),  a  fall, 
laceration  or  cut  into  the  perineum  (traumatism  from  without), 
"  or  as  a  consequence  of  retrostrictural  dilatation,  when  all  ducts 
are  stretched  and  the  mucosa  is  eroded  and  inflamed  by  stag- 
nated and  alkaline  urine  "  (Horowitz") . 

Cowper's  glands  being  situated  between  the  two  layers  of  the 
triangular  ligament,  and  also  being  contained  by  the  deep  peri- 

1  Posner  :  Therapie  der  Harnkrankheiten,  Berlin,  1895. 

^Horosvitz:  "Die  Krankheiten  der  Cowperschen  Driisen.  "  Zuelzer  and 
Oberlaender"s  Klinisches  Handbuch  der  Harn- und  Sexual-Organe,  vol.  iii., 
Leipzig,  1894. 


COMPLICATIONS   AND   SEQUELJE    OP   GONORRHCEA.  51 

neal  fascia,  their  inflammatory  swelling  is  necessarily  limited. 
Their  pressure  upon  these  unyielding  tissues  not  only  jjroduces 
intense  pain,  but  also  renders  the  disease  externally  unrecog- 
nizable until  these  envelopes  have  yielded.  Moreover,  as  the 
ducts  of  Cowper's  glands  empty  into  the  bulbous  urethra,  their 
involvement  by  gonorrhoea  is  easily  comprehensible.  Owing  to 
the  fact  that  the  majority  of  cases  of  Cowperitis  undergo  resti- 
tution, it  may  be  that  they  are  oftener  infected  than  is  supposed 
and  that  the  comijlication  passes  off  unobserved. 

In  the  second  or  third  week  of  neglected  or  improperly 
treated  gonorrhoea,  when  the  affection  has  invaded  the  posterior 
urethra,  Cowperitis  is  most  likely  to  become  manifest.  Then 
slight  fever  may  set  in,  with  a  sensation  of  perineal  discomfort. 
The  mechanical  impediment  produces  difficulty  of  urination  and 
some  pain  on  defecation.  Shortly  thereafter  lancinating  pains 
penetrate  the  region;  these  are  aggravated  by  pressure  upon 
the  perineum,  by  sitting  and  walking.  Even  when  lying  down 
there  is  a  sensation  of  perineal  tension.  The  pains  on  evacu- 
ating the  rectum  and  bladder  increase,  especially  at  the  conclu- 
sion of  urination,  due  to  contraction  about  the  inflamed  gland 
by  the  transverse  fibres  of  the  compressor,  as  it  forces  out  the 
last  part  of  the  urine. 

When  but  one  gland  is  involved,  as  is  ordinarily  the  case,  it 
is  evidenced  by  small,  hard,  exceedingly  sensitive  swelling  at 
the  corresponding  side  of  the  raphe  about  midway  between  the 
scrotum  and  the  anus.  This  tumor  may  grow  to  the  size  of  a 
chestnut,  or  become  as  large  as  a  pigeon's  egg,  over  which  the 
skin  is  movable,  while  it  retains  its  normal  appearance.  Palpa- 
tion of  this  tumor  will  not  aid  materially  in  diagnosis,  as  its 
painfulness  prevents  deep  pressure.  Digital  pressure  under 
anaesthesia  would  be  unwise,  as  it  might  cause  a  rupture  of  the 
distended  gland  into  the  surrounding  tissues  with  consequent 
danger  of  purulent,  and  possible  subsequent  urinary  infiltration. 
The  finger  inserted  into  the  rectum,  its  tip  gently  pressed  forward 
between  the  external  and  internal  sphincters,  will  reveal  a  round, 
smooth,  hot,  painful  tumor  below  the  prostate.  When  the  tumor 
is  found  on  one  side  of  the  mesian  line,  no  doubt  can  obtain  re- 
garding the  diagnosis.  When  bilateral  Cowperitis  exists,  and 
if  there  be  much  infiltration  and  distention  of  the  surrounding 
tissues,  the  diagnosis  is  more  difficult. 


52  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

The  following  will  aid  in  the  differentiation : 

"When  Cowperitis  sets  in,  the  urethral  discharge  is  ordinarily- 
much  decreased  or  arrested  entirely. 

Simple  perineal  abscess  causes  no  compression  inward  or 
upward,  and  consequently  does  not  interfere  with  urination. 
Only  when  it  is  yerj  large  will  it  produce  pain  on  defecation. 

Peri-urethral  abscess  of  the  bulb  is  invariably  found  cen- 
trally located  about  the  raphe,  and  is  situated  nearer  the  scro- 
tum than  is  Cowperitis. 

Resolution  ordinarily  takes  place  within  fourteen  days  under 
proper  treatment.  This  consists  in  mild,  gently  administered 
washings  of  the  anterior  urethra,  rest  in  bed,  long-continued, 
very  hot  baths  twice  a  day,  saline  laxatives  to  keep  the  stools 
soft,  and  a  hot-water  bag  to  the  perineum.  If  the  pain  is  very 
severe,  morphine  hypodermically  may  be  required.  When  em- 
ployed, the  needle  should  be  as  carefully  sterilized  as  for  use 
elsewhere,  and  care  should  be  taken  not  to  inject  the  solution 
into  the  tumor  itself,  lest  suppuration  be  precipitated  thereby. 

When,  however,  the  inflammation  is  allowed  to  increase  and 
the  gland  and  periglandular  tissues  undergo  suppuration,  Cow- 
peritis assumes  its  grave  form.  One  or  more  chills,  fever, 
throbbing  in  the  perineum  show  that  pus  has  formed,  even  if 
fluctuation  is  not  perceptible.  If  the  case  is  then  neglected  the 
abscess  may  break  into  the  perineum,  the  urethra,  or  the  rec- 
tum. If  it  breaks  toward  the  perineum  it  may  dissect  the  skin 
from  its  underlying  tissues,  leaving  it  hanging  like  torn  rags 
after  perforation.  Partial  gangrene  of  the  scrotum  may  also 
result.  Such  a  spontaneous  rupture  may  produce  urethral  and 
rectal  fistulse,  whose  treatment  is  often  very  difficult. 

When  such  dangers  are  announced  free  incision  should  be 
immediately  made.  In  making  this  incision  it  will  be  well  to 
support  the  suppurating  gland  by  the  index  finger  in  the  rectum. 
After  incision  the  cavity  should  be  curetted  or  irrigated  or  both, 
and  packed  with  iodoform  gauze.  It  will  be  well  to  guard 
against  urinary  fistula,  by  keeping  the  urethra  protected  by 
means  of  permanent  catheterization,  until  the  abscess  has  suffi- 
ciently healed. 

Chronic  Cowperitis  shows  itself  as  a  hard,  not  very  painful 
nodule  at  one  side  of  the  raphe,  which  when  pressed  upon  dis- 
charges a  turbid,  milk-like  secretion  from  the  urethra.     If  it 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  53 

results.after  rupture  of  the  abscess,  tliis  discharge  issues  from 
the  perineum  or  into  the  rectum. 

It  is  always  well  to  keep  in  mind  that  Cowper's  glands  may 
be  the  seat  of  a  tuberculous  infection  and  that  therefore  the  dis- 
charge therefrom  should  be  examined  for  the  characteristic 
bacilli. 

Cystitis. — Inflammation  of  the  bladder  pre-existing,  compli- 
cating or  following  gonorrhoea  is  too  vast  a  subject  to  be  more 
than  merely  outlined  in  a  small  sketch.  That  persons  with  cys- 
titis acquiring  gonon'hoea  can  suffer  its  extension  to  the  bladder 
is  often  proven.  That  gonococci  can  find  a  culture  medium  in 
a  healthy  bladder  mucosa  is  denied.  This  negation  seems  to 
be  borne  out  by  the  thousands  of  intravesical  irrigations  per- 
formed daily  in  acute  anterior  gonorrhoea.  Despite  all  careful 
washings  of  the  anterior  urethra,  the  irrigation  fluid  must  cer- 
tainly carry  gonococci  into  the  healthy  bladder.  Yet  no  cystitis 
ever  results.  It  may  be  held  that  the  gonococci  so  carried  are 
brought  into  the  bladder  by  an  antiseptic  solution.  While  this 
is  true,  no  solution  strong  enough  to  destroj"  gonococci  could  be 
injected  into  the  bladder  without  injuring  its  mucosa.  On  the 
other  hand,  cystitis  has  often  been  produced  by  inserting  an  in- 
strument through  a  urethra  infected  with  gonorrhoea  into  the 
bladder.  The  bladder  wall  may  have  been  bruised  sufficiently 
thereby  to  injure  its  protecting  epithelium. 

Whether  gonorrhoea  can  invade  the  bladder  by  mere  conti- 
nuity of  surface  is  still  one  of  the  disputable  questions.  That 
gonococci  can  be  carried  beyond  the  strong  compressor  urethrse 
is  proven  many  times ;  that  they  can  traverse  the  weak  sphinc- 
ter of  the  bladder  is  indubitable.  But  whether  the  healthy 
bladder  epithelium  ever  can  offer  them  food  is  not  at  all  estab- 
lished, and  from  all  experience  is  more  than  doubtful. 

When,  however,  the  urethritis  is  of  a  mixed  character,  i.e., 
when  the  gonococcus  is  associated  with  other  microbes,  such  as 
the  bacterium  coli  commune,  the  bladder  epithelium  3-ielding 
to  the  latter  may  open  the  way  for  gonorrhoeal  infection. 

Usually  the  region  of  the  sphincter  and  of  the  trigone  is  the 
seat  of  such  extension  of  inflammation,  and  has  been  ajDtly 
named  urethrocystitis  by  Finger.  The  great  rarity  with  which 
this  inflammation  extends  to  the  rest  of  the  bladder  conflrms 
the  view  of  immunity  of  its  lining  epithelium  to  invasion  by  the 


54  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

gonococcus.  Such  invasion  must  be  due  to  lesions  produced  by 
other  bacteria. 

The  symptoms  of  gonorrhoea!  cystitis  closely  resemble  those 
of  posterior  urethritis.  The  urgency  and  frequency  of  urina- 
tion are  about  the  same.  The  patient  also  strains  during  and 
after  ejecting  small  quantities  of  urine;  he  experiences  the  sen- 
sation as  if  the  bladder  still  contained  urine.  In  this  urethro- 
cystitis, however,  the  patient  is  somewhat  relieved  while  lying 
down,  until  the  urine  has  filled  the  most  dependent,  not  in- 
flamed, part  of  the  bladder.  This  limit  passed,  the  moment  the 
urine  touches  the  diseased  region  it  re-establishes  the  urgency 
and  the  pain,  which  burns  and  scalds  along  the  entire  urethra. 
In  this  it  differs  from  acute  posterior  urethritis,  which  is  not 
relieved  by  any  position,  because  the  weak  sphincter  vesicas 
yields  to  slight  urinary  pressure  and  lets  the  fluid  escape  into 
the  inflamed  posterior  urethra,  where  it  sets  up  urgency,  strain- 
ing, and  pain  after  each  micturition.  The  ejection  of  some 
drops  of  -pwce  blood  after  each  urination,  with  the  other  symp- 
toms just  cited,  is  pathognomonic  of  posterior  urethritis. 

The  examination  of  the  urine  in  portions,  for  differential 
diagnosis,  is  difficult  in  localized  gonorrhoeal  cystitis  (urethro- 
cystitis) when  frequent  urination  prevents  sufficient  accumu- 
lation within  the  bladder.  In  such  case  the  bladder  may  be 
washed  with  a  warm  boric-acid  solution  until  its  outflow  is 
clear,  when  a  carefully  sterilized  soft  catheter  is  inserted  and 
fastened  in  place  for  an  hour  or  two,  if  it  can  be  tolerated  so 
long.  The  catheter  is  clamped,  or  plugged  with  a  "fausset" 
(spigot).  If  the  urine  that  comes  through  it  at  the  end  of  this 
time  carries  pus  with  it,  the  pus  probably  is  from  the  bladder. 
The  differentiation,  however,  is  open  to  criticism.  Even  if 
pain  from  presence  of  the  catheter  be  not  so  great  as  to  prevent 
its  use,  there  may  be  sufficient  "back-flow"  of  pus  from  the 
posterior  urethra  to  give  the  impression  of  cystitis,  by  the  pus 
the  accumulated  urine  carries.  The  oidj  reliable  method  of 
differentiation  is  by  means  of  the  microscope.  If  the  urine 
extruded  shows  a  preponderance  of  bladder  epithelium,  and 
especially  that  of  its  middle  or  lower  layers,  the  existence  of 
cystitis  is  established  beyond  peradventure. 

Pus  in  the  urine  is  easily  recognized  by  adding  to  it  satu- 
rated solution  of  caustic  potash,  and  twirling  the  tube  containing 


COMPLICATIONS   AND   SEQUELJE   OF   GONORRHCEA.  55 

tlie  mixture  in  as  good  an  imitation  of  tlie  centrifuge's  action 
as  can  be  done  by  tlie  hand.  The  urine  becomes  clear,  and  the 
separated  pus  assumes  a  ropy,  mucoid  form.  Donne,  who  de- 
vised this  test,  forcibly,  albeit  inelegantly,  describes  it  as  "  rot- 
zig"  (snotty).  Eepugnant  as  is  the  adjective,  none  seems  more 
apt  for  precise  description.  In  cold  weather  this  reaction  may 
not  be  very  prompt ;  slightly  warming  the  tube  will  then  hasten 
it.  If  this  does  not  then  result,  the  turbidity  is  due  to  phos- 
phaturia,  albuminuria,  bacteruria,  or  an  excess  of  epithelia. 

Another  si^ecimen  of  the  same  urine  may  be  heated.  If  it 
grows  more  turbid  over  the  flame,  it  shows  that  it  contains 
either  earthy  phosphates  or  albumin.  The  addition  of  acetic 
acid  will  clear  the  urine  if  phosphates  have  rendered  it  turbid. 
If  acetic  acid  does  not  change  or  even  somewhat  intensifies  the 
turbidity,  it  proves  the  presence  of  albumin.  The  latter,  how- 
ever, is  always  present  with  pus. 

When  neither  heating  nor  acidulation  affects  the  urine,  bac- 
teruria will  usually  be  proven  by  the  microscope. 

The  treatment  of  gonorrhoeal  cj^stitis,  which  almost  invari- 
ably presents  itself  as  urethrocystitis,  is  practically  the  same  as 
that  advised  for  acute  posterior  urethritis  and  acute  prostatitis. 

DrvEETiCLE,  urethral— Bee  Urethral  Diverticulum. 

Epididymitis,  or  Oechi-epididymitis,  or  both,  like  most  of  the 
other  complications  of  gonorrhoea,  may  result  from  a  precedent 
condition  or  from  a  new  gonorrhoea.  If  preceding  a  new  gonor- 
rhoea, inflammation  of  the  epididymis  or  testicle  or  both  may 
be  due  to  traumatism,  non-gonorrhoeal  infection,  tuberculosis, 
or  syphilis. 

As  both  the  epididymis  and  testicle  are  frequently  affected 
together,  it  is  often  impossible  to  decide  whether  one  or  the 
other  is  free  from  inflammation,  and  as  the  treatment  of  both 
ailments  does  not  differ,  there  is  ample  warrant  for  considering 
them  conjointly.  * 

The  frequent  difficulty,  and  often  impossibility,  of  positively 
establishing  that  the  testicle  is  not  affected  in  gonorrhoeal  epi- 
didymitis may  have  led  to  the  assumption  that  it  limits  itself 
to  the  epididymis.  Further  development  of  radiography  of  the 
soft  tissues  will  probably  soon  lead  to  finer  differentiation  with 
consequent  improvement  in  therapeutics.  Carl  Beck,  of  New 
York,  made  distinct  pictures  in  which  even  the  walls  of  the 


56  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

arteries  were  plainly  radiographed  in  the  living ;  there  is  every 
reason,  therefore,  to  hope  for  the  outcome  above  expressed,  with 
all  its  advantages  to  diagnosis  and  treatment. 

The  pathological  changes  evidenced  by  post-mortem  exami- 
nations and  the  experimental  examinations  made  by  Malassez 
and  Terrillou  (quoted  by  Finger')  primarily  show  the  testicle 
not  to  be  involved.  As,  however,  post-mortem  changes  may  not 
have  left  evident  serous  infiltration  or  sanguinary  engorgement, 
these  observations  cannot  be  taken  as  finally  decisive. 

These  authors  found  the  epididymis  enlarged,  hypersemic, 
occasionally  with  circumscribed  foci  of  pus;  in  old  cases  the 
epididymis  was  tough  and  calloused.  The  tunica  vaginalis 
testis  showed  acute,  serous,  or  serofibrinous  vaginalitis.  The 
vas  deferens  was  often  thickened.  The  microscope  showed  a 
catarrh  of  the  seminal  ducts  and  parvicellular  infiltration  of 
its  connective-tissue  envelope.  The  epithelium  of  the  seminal 
ducts  was  turbid  and  swollen,  deprived  of  its  cilia ;  in  still  older 
cases  it  was  entirely-  absent,  and  the  lumen  of  the  canals  filled 
only  with  spermatozoa,  with  parvicellular  infiltration,  or  fibrous, 
calloused  by  connective-tissue  change  of  the  infiltrate,  in  ad- 
vanced cases.  The  changes  in  the  vas  deferens  also  begin  wdth 
catarrh  of  the  mucosa,  to  which  parietal  infiltration  and  thick- 
ening of  the  walls  are  added  later  on. 

It  is  held  that  epididymitis  sets  in  most  frequently  during 
the  third  week  after  infection.  Finger  {op.  cit.)  collected  the 
data  of  several  authors,  showing  that  in  1,015  gonorrhoeas,  epi- 
didymitis appeared  in  the  first  week  after  infection  in  46  cases ; 
second  week  in  157 ;  third  week  in  132 ;  fourth  week  in  191 ;  fifth 
week  in  132 ;  sixth  week  in  64 ;  seventh  week  in  44 ;  eighth  week 
in  61 ;  from  three  to  six  months  after  in  117 ;  from  six  to  twelve 
months  in  52 ;  two  years  in  9 ;  three  years  in  7 ;  four  years  in  2 ; 
and  seven  years  after  in  1. 

The  very  long  intervals  between  gonorrhoeal  infection  and 
epididymitis  in  some  cases  being  evident  from  the  above,  its 
possibility  must  not  be  forgotten  when  a  patient  has  epididymi- 
tis with  a  long  passed  history  of  clap.  Then  often  unnecessary 
castration  for  presumed  tuberculosis  will  be  avoided.     Senn^  in 

'  Finger :  "  Die  Hoden  mid  Nebenhoden."  Klinisclies  Handbuch  der  Harn- 
und  Sexuaiorgane,  vol.  iii.,  1894. 

^  Senn  •  Tuberculosis  of  the  Genito-Urinary  Organs,  Saunders,  1897. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  5T 

one  of  liis  admirable  works  says:  "Except  in  cases  of  acute  dif- 
fuse miliary  tuberculosis,  the  essential  organ  of  generation  in 
man  is  seldom  the  seat  of  primary  tuberculosis."  On  the  other 
hand,  gonorrhoea!  epididymitis  and  traumatism  are  often  the 
exciting  causes  of  tuberculous  disease  of  the  testicle  and  epi- 
didymis. Senn'  cites  an  illustrative  case  reported  by  Birch- 
Hirschfeld  {ArcMv  fur  Heilkunde,  1871,  Heft  6) : 

"  A  soldier,  24  years  of  age  and  in  perfect  health,  contracted 
gonorrhoea  which  led  to  acute  epididymitis.  In  the  course  of 
eight  days  he  died  of  miliary  tuberculosis.  Miliary  tuberculosis 
was  found  in  the  peritoneum,  especially  well  marked  at  the  in- 
ternal inguinal  ring  on  the  side  of  the  affected  testicle ;  miliary 
tuberculosis  of  the  pleurae,  lungs,  meninges,  liver,  spleen,  and 
kidneys  also  existed;  the  epididymis  was  transformed  into  a 
cheesy  mass.  In  the  testicle  itself  numerous  infcercanalicular 
miliary  tubercles  were  found,  with  a  few  cheesy  nodules  the  size 
of  a  pea." 

In  all  cases  of  gonorrhoea  the  patient  should  wear  a  well- 
fitting  suspensory  bandage.  I  am  not  aware  that  any  statistics 
exist  showing  the  value  of  this  bandage  as  a  precautionary  meas- 
ure. It  seems,  however,  reasonable  to  assume  that  the  scrotal 
contents,  so  supported,  must  be  less  exposed  to  traumatism 
than  they  would  be  if  left  to  dangle  by  the  often  relaxed  gen- 
eral condition  of  depressed  vital  tone. 

The  selection  of  a  suspensory  bandage  is  not  an  unimportant 
matter.  The  form  ordinarily  dispensed,  having  no  "back 
straps"  to  draw  the  bag  perineumward,  cuts  the  posterior 
aspect  of  the  scrotum  and  pulls  it  into  an  abnormal  position. 
The  bag  itself  is  of  thick  material  in  which  the  scrotal  sweat 
cakes  and  hardens,  irritating  the  skin,  unless  the  bag  is  fre- 
quently washed.  To  avoid  these  defects,  the  suspensories  should 
be  of  the  forms  sold  as  the  "  Syracuse  "  or  "Army  and  Navy,"  or 
"  Schnotter  "  suspensories.  These  have  straps  passing  from  the 
centre  of  the  posterior  boundary  of  the  bag,  between  the  thighs, 
over  the  nates,  to  be  fastened  to  the  belt.  Eecently  the  bags 
have  been  made  of  a  strong  but  very  light  linen  mesh,  which 
not  only  firmly  holds  the  scrotum  in  place,  but  is  also  cool  and 
comfortable. 

Gonorrhoeal  epididymitis,  orchitis,  or  orcho-epididymitis  is 

'  Op.  cit.,  p.  54. 


58  THE   IRRIGATION   TREATMENT   OP   GONORRHCEA. 

usually  ushered  in  by  vague  aeliing,  sliarp  sti telling,  or  continued 
neuralgic  pains  along  the  groin.  Sometimes  the  pain  is  dis- 
tinctly defined  as  proceeding  the  length  of  the  spermatic  cord 
and  dipping  into  the  lower  abdomen.  The  pain  may  be  aggra- 
vated by  standing  or  walking,  and  not  relieved  by  sitting.  Ex- 
amination of  the  cord  shows  the  vas  slightly  enlarged  and  tender. 

Occasionally  none  of  the  pain  or  tenderness  described  above 
warns  the  patient  or  the  physician  of  the  approaching  complica- 
tion. This  fact  emphasizes  the  need  of  daily  examination. 
When  thickening  and  slight  tenderness  of  the  vas  on  pressure 
between  the  fingers  are  found,  active  steps  should  be  at  once 
,,taken  to  abort  the  inflammation. 

In  some  cases,  when  the  patient  is  not  observant  or  when 
the  physician  is  compelled  to  omit  daily  examinations,  the  com- 
plication appears  to  come  on  suddenly.  A  dragging  pain  is 
fixed  in  the  testicle;  the  epididymis  swells  rapidly";  the  scrotum 
over  it  takes  on  oedema  and  soon  becomes  purplish.  The  pain 
nauseates  the  patient ;  it  may  even  lead  to  vomiting,  as  after  a 
kick  or  blow  upon  the  testicle.  The  urethral  discharge  usually 
is  diminished  or  disappears  during  the  acuitj"  of  inflammation 
of  the  scrotal  contents. 

The  epididymis  is  sensitive  to  touch,  but  this  sensitiveness 
varies.  In  some  cases  it  bears  no  relation  at  all  to  the  increased 
size  of  the  epididymis.  A  \erj  slight  enlargement  of  this  gland 
vdSij  be  exquisitely  tender  to  the  touch,  while  when  it  is  so  en- 
larged as  almost  to  entirely  envelop  the  testicle  and  exceed  it 
materially  in  size,  it  may  be  rather  roughly  handled  without 
producing  pain. 

Not  infrequently  the  tunica  vaginalis  becomes  involved,  with 
consequent  serous  effusion.  The  acute  hydrocele  so  resulting 
may  envelop  the  whole  testicle  in  a  large,  tense  swelling,  mis- 
leading the  inexperienced  to  a  diagnosis  of  orchitis.  The  trans- 
lucency  of  the  fluid  and  the  enlarged  epididymis  behind  the 
swelling  will  prevent  this  error. 

If  the  patient  can  walk,  he  spreads  his  bent  legs  wide  apart, 
carries  his  body  forward  as  if  in  continual  desire  to  rest  his 
hands  upon  his  knees.  When  about  to  sit  down,  he  grasps  the 
chair  and  lets  his  body  down  slowly.  Rising  from  the  chair  is 
accompanied  by  the  same  painful  effort,  as  is  any  attempt  to 
cross  his  knees. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  59 

In  tlie  erect  posture,  tlie  pain  is  increased.  The  weight 
of  the  swelling  drags  upon  the  spermatic  veins,  reducing  their 
lumen;  the  blood  from  the  testicle  cannot  therefore  return  up- 
ward. The  so  augmented  tension  and  pressure  may  cause  the 
pain  to  be  reflected  to  the  perineum,  rectum,  back,  bladder, 
down  the  thighs,  abdomen,  and  the  chest.  When  the  reflex 
pains  are  as  extensive  as  described,  chills,  fever,  anxiety,  and 
mental  depression  may  become  so  marked  as  to  overshadow  the 
condition  that  provokes  them.  The  abdomen  may  swell  and 
become  very  sensitive ;  nausea,  vomiting,  and  collapse  may  con- 
vey the  idea  that  the  patient  has  peritonitis.  These  reflex 
symptoms  usually  subside  rapidly,  and  the  swollen  epididymis 
remains  in  evidence  of  their  cause. 

In  undescended  testicle,  to  which  inflammation  is  communi- 
cated, the  patient  may  have  all  the  symptoms  of  strangulated 
hernia.  Emptiness  of  the  scrotum,  however,  will  prevent  this 
mistake. 

•  With  prompt  and  proper  treatment,  inflammation  of  the 
scrotal  contents  generally  ends  in  resolution.  The  acute  symp- 
toms usually  subside  in  a  week  or  ten  days. 

When  through  neglect  suppuration  occurs,  there  are  in- 
creased pain,  chills,  fever,  sweating,  and  abscess  is  made  evident 
by  fluctuation.  On  opening  it,  the  entire  epididymis  may  pro- 
lapse out  of  the  wound,  especially  if  the  operation  has  been  un- 
duly delayed.  The  delay  may  also  lead  to  destruction  of  the 
entire  scrotal  contents. 

The  acute  hydrocele  resulting  from  acute  epididymitis  often 
becomes  chronic. 

The  most  frequent  result  of  epididymitis  is  the  formation  of 
a  hard,  painless  nodule  at  its  head  or  its  tail.  This  nodule  in 
no  wise  locally  disturbs  the  patient ;  in  some  cases  it  rivets  his 
attention  and  becomes  the  object  of  his  continual  thoughts,  evok- 
ing most  persistent  neurasthenia. 

Treatment. — In  a  small  number  of  cases  the  vas  deferens 
shows  the  first  sign  of  its  carrying  infection  to  the  epididymis 
and  possibly,  through  it,  to  the  testicle.  The  funiculitis  then 
evidences  itself  by  pain  and  swelling  in  the  inguinal  region. 
Copious  leeching  of  the  region  will  then  relieve  the  pain  and  in 
many  cases  prevent  active  involvement  of  the  scrotal  contents. 

If  the  epididymis  is  found  swollen  at  the  same  time,  and 


60 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


there  be  enougli  pain  to  warrant  it,  the  patient  sliould  be  kept 
in  bed.  A  board  or  a  slieet  of  tin,  about  tlie  size  of  a  cigar-box 
lid,  should  be  cut  so  that  it  will  lie  comfortably  upon  the 
thighs  and  support  the  testicles.  A  three-inch  gauze  bandage 
is  then  wrapped  smoothly  entirely  about  this  support  to  insure 
its  softness.  Over  this  a  sheet  of  impermeable  tissue  is  folded 
to  fit  neatlj'. 


Fig.  14.— Support  for  Testicles. 


Four  or  sis  layers  of  gauze  eight  by  ten  inches  are  then  soaked 
in  an  antiseptic  solution  of  five  per  cent,  carbolic  acid,  1 : 6,000 
bichloride  or,  if  preferred  lead  and,  opium  lotion,  and  wrapped 
gently  around  the  testicles.  The  solution  may  be  applied  hot 
or  cold  as  may  prove  most  grateful  to  the  patient,  and  should 
be  renewed  every  fifteen  or  twenty  minutes. 

If  the  pain  is  not  relieved  in  forty-eight  hours,  the  case 
should  be  treated  as  described  further  on. 

When  the  funis  is  not  at  all  or  but  slightly  swollen,  strap- 
ping the  testicle  will,  in  the  majority  of  eases,  afford  instant, 
complete  relief  from  pain  and  will  cut  short  the  disease.  This 
treatment  should,  however,  not  be  attempted  unless  the  physician 
is  thoroughly  familiar  with  its  technique  and  has  the  firmness 
to  give  the  patient  that  short  increase  of  x>ain  which  strapping 
inevitably  entails. 

The  technique  of  strapping  a  testicle  as  I  employ  it  is  a 
modification  of  Fricke's  method : 

The  patient  lies  on  a  table,  his  legs  extended  flat  upon  it  and 
somewhat  abducted;  he  or  an  assistant  slightly  supports  the 
scrotum  while  the  dressings  are  being  prepared.  Two  strips 
are  cut  from  a  three  or  four  inch  gauze  bandage,  according  to 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHOEA.  61 

the  size  of  the  swelling,  and  long  enough  to  cover  the  scrotum 

from  the  perineum  to  the  pubis.     These  strips  are  smeared  with 

an  ointment,  slightly  modified  from  that  proposed  by  Casper,  of 

Berlin,  and  composed  of  ichthyol 

2.5,  guaiacol  5.0,  ung.   hydrarg.       [    J-\ 

10,  vaselin  and  lanolin,  p.  se.  ad      \ 

30.0.      The  use  of  these   strips       \    i  1 

renders  shaving  the  scrotum  un-         t\ 

necessary. 

The  neck  of  the  scrotum  of  -^     :;v^v^ 

the  diseased  side  is  then  grasped 
between  the  left  thumb  and  mid-  f.r- 

die  or  index  finger,  and  with  in-  /*:  B 

creasing  pressure  the  testicle  is 
forced  to  the  bottom  of  the  scro- 
tum. The  compressing  fingers 
are  steadily,  forcibly  contracted 
until  the  region  about  the  funis  ,,,, 

is  reduced  to  its  smallest  possible 
calibre.      Without   releasing  the 

°.  Fig.    15.— The   First   Strip   of  Adhesive 

grasp  oi  the  fingers  a   hali-mch  piaster. 

strip   of  strong   adhesive  plaster 

is  firmly  wrapped  immediately  below  the  fingers  so  tightly  as  to 
convey  the  impression  that  the  funis  might  be  strangulated 
thereby.  This  is  the  most  painful  part  of  the  whole  procedure. 
If  not  thoroughly  done,  the  entire  purpose  of  the  strapping  will 
be  thwarted :  the  patient  will  experience  no  relief,  the  case  will 
be  aggravated,  the  scrotum  injured  and  its  contents  exposed  to 
abscess  formation.  Cases  are  not  rare  in  which  physicians, 
guided  more  by  sympathy  for  their  patients  than  by  steadfast- 
ness of  purpose,  have  strapped  the  swelling  so  that  the  testicle 
was  forced  up  toward  or  almost  into  the  inguinal  ring  and  the 
epididymis  away  from  the  testicle. 

After  the  first  strip  of  adhesive  plaster  (which  I  think  may 
be  properly  called  the  "  choker  ")  is  firmly  applied,  the  superficial 
veins  of  the  scrotum  will  for  a  moment  enlarge  and  stand  as 
blue,  more  or  less  tortuous  strings  beneath  the  skin.  One  of 
the  gauze  strips  smeared  with  the  Casper  ointment  is  firmly  and 
smoothly  laid  from  the  posterior  neck  of  the  swelling  to  its  an- 
terior aspect,  and  the  second  strip  is  similarly  applied  at  right 


62 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


angles  to  the  first.  A  second  "  choker "  about  three  to  four 
inches  wide  is  now  firmly  wrapped  around  the  root  of  the  tumor 
covering  the  first  "  choker "  and  holding  the  four  ends  of  the 
gauze  strips  in  place.  Then  an  adhesive  strip  half  an  inch  wide 
and  of  sufficient  length,  is  firmly  attached  to  the  centre  of  the 
posterior  (perineal)  aspect  of  the  choker,  tightly  drawn  over 
the  testicle  and  attached  to  the  centre  of  the  anterior  part  of 
the  choker.  A  second  strip  is  similarly  placed  from  the  choker 
at  the  external  surface  of  the  scrotum  to  the  mesian  surface,  at 

right  angles  to  the  first  strip. 
A  third  strip  is  attached  to  the 
choker,  immediately  adjoining 
and  slightly  overlapping  the 
second  strip's  entire  course. 
Successive  strips  are  placed  in  the 
same  manner  until  the  entire  tes- 
ticle is  firmly  encased. 

It  will  be  found  necessary  to 
heat  thoroughly  each  strip  and  to 
apply  it  as  hot  as  it  can  be  borne 
by  the  patient,  to  secure  its  ad- 
hesion  to   the  grease  that  oozes 
through  the  gauze.     It  will  also 
be    convenient   to    apply  a  new 
choker  after  each  three  or  four 
longitudinal  strips  are  applied. 
All   attention  should    be    di- 
rected to  applying  the  strips  smoothly,  and  with  as  firm  and 
even  pressure  as  possible. 

After  the  last  longitudinal  strip  is  applied,  the  whole  dress- 
ing should  be  reinforced  by  a  final  choker  about  six  inches 
long.  Two  or  three  turns  of  the  choker  are  made  about  the 
neck  of  the  tumor,  the  remaining  strip  is  made  to  envelop  the 
other  longitudinal  strips  by  interrupted  spiral  turns,  returning 
to  the  neck. 

The  projecting  ends  of  the  adhesive  plaster  about  the  neck 
of  the  scrotum  are  then  cut  off  closely  above  the  choker;  the 
projecting  ends  of  the  gauze  are  also  trimmed  but  allowed  to 
extend  about  one-eighth  of  an  inch  above  the  choker,  to  protect 
the  skin  from  erosions  that  otherwise  w^ould  be  likely  to  result. 


Fig.  16.— Testicle  Strapped. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  63 

Before  tlie  patient  rises,  a  large  suspensory  bandage  ^^'itli 
back-straps  is  firmly  applied,  after  enveloping  the  wliole  testicle 
in  a  layer  of  cotton.  Absorbent  cotton  having  lost  its  resiliency 
in  being  prepared,  should  not  be  used  for  this  purpose. 

The  whole  procedure,  from  placing  the  patient  on  the  table 
to  buckling  the  suspensory  bandage,  should  not  occupy  over  five 
minutes;  the  increased  pain  caused  by  applying  the  first  choker 
should  not,  with  ordinary  skill,  extend  over  ten  seconds,  the 
other  manipulations  should  be  comparatively  painless. 

After  the  testicle  is  drawn  as  closely  as  possible  to  the  pubis 
by  the  suspensory  bandage,  the  patient  is  told  to  arise.  If  all 
parts  of  the  work  have  been  properly  performed,  it  will  be 
found  that  the  patient  can  stand  upright;  that  he  can,  when 
holding  his  heels  and  toes  together,  take  up  a  small  object  lying 
immediately  in  front  of  his  toes ;  that  he  can  stand,  walk,  turn 
rapidly,  sit  down,  get  up,  cross  his  legs  absolutely  without  pain 
and  with  no  sensation  about  his  genitals  further  than  the  feeling 
of  some  bulk  between  his  legs,  which,  however,  is  but  slightly 
or  not  at  all  uncomfortable. 

-  The  exhilaration  produced  by  the  sudden  cessation  of  local 
and  reflex  pains  and  the  stopping  of  all  constitutional  effects 
thereof  make  the  patient  exceedingly  willing  to  return  in  forty- 
eight  hours  for  a  second  strapping.  Usually  the  longitudinal 
straps  will  then  be  found  loosely  encasing  the  scrotum.  A 
grooved  director  passed  under  the  choker  into  the  space  between 
the  scrotum  and  the  plaster  strips  serves  as  a  guide  for  strong 
scissors  to  cut  the  choker  at  the  centre  of  its  anterior  asfject. 
The  hair  to  which  it  is  attached  should  be  cut  through,  care  be- 
ing taken  not  to  snip  the  skin.  When  all  the  hairs  are  cut,  pass 
the  scissors  through  the  anterior  aspect  of  the  entire  casing, 
which  can  then  be  easily  removed.  The  swelling  will  then  be 
found  reduced  to  one-third  or  one-fifth  of  its  former  size.  If 
any  excoriations  have  resulted  from  defects  in  the  dressing,  they 
should  be  dusted  with  nosophen  and  cotton  packed  into  a  snugly 
fitting  suspensory  bandage  applied  over  it.  If  no  excoriations 
have  resulted,  and  especially  if  some  tenderness  still  remains, 
the  strapping  should  be  reapplied  and  repeated  every  forty-eight 
hours.  Some  cases  may  require  as  many  as  four  such  strap- 
pings to  reduce  the  inflammation  to  a  subacute  state,  which 
then  may  be  treated  by  applications  of  the  Casper  ointment  on 


64  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

gauze  strips  twice  dailj^  These  strips  should  then  be  covered 
bj^  a  thick  layer  of  cotton  and  impermeable  tissue  over  the  cot- 
ton, all  held  firmly  in  place  by  a  well-fitting  suspensory  bandage. 

In  some  cases,  having  reached  this  stage,  resorption  of  the 
swelling  seems  to  be  hastened  hj  galvanism  employed  every 
second  day.  At  the  first  seance  the  moistened  negative  elec- 
trode may  be  applied  to  the  scrotum  and  the  positive  to  the 
thigh.  The  seance  may  last  five  minutes  and  two  milliamperes 
be  employed.  At  the  second  seance  the  poles  should  be  changed, 
the  time  lengthened  to  six  minutes  and  the  current  increased 
to  three  milliamperes.  At  each  subsequent  seance  the  poles 
should  be  changed,  the  application  extended  one  minute  and  the 
amperage  increased  one  milliampere.  The  use  of  galvanism 
should  not  be  carried  to  a  painful  degree  and  the  site  of  applica- 
tion of  the  positive  pole,  while  kept  firmly  applied,  should  be 
continually  moved  to  prevent  excoriations. 

Sometimes  the  patient's  timidity  or  the  physician's  lack  of 
fortiter  in  re  (never  incompatible  with  suaviter  in  modo)  prevents 
strapping  the  testicle  in  the  class  of  cases  cited.  Then  the 
indications  for  rest,  elevation,  warmth,  and  moisture  can  be 
approximately  attained  by  the  use  of  specially  constructed  sus- 
pensories. These  were  first  suggested  by  Horand,  and  sub- 
sequently modified  by  Langlebert,  von  Zeissl,  Casper,  Falk- 
son,  Letzel,  White  and  Martin,  and  others.  They  differ  from 
suspensory  bandages  mentioned  before,  in  being  much  larger, 
stronger,  and  adjustable  not  only  in  the  bodj^  and  perineal  straps, 
but  also  in  having  adjustable  scrotal  bags.  Their  cost  is,  how- 
ever, high.  In  cases  in  which  the  bandages  mentioned  before 
will  not  suffice,  they  certainly  are  serviceable.  They  are  em- 
ployed as  was  directed  for  their  use  after  strapping. 

A  substitute  for  strapping  and  suspensories  is  devised  by 
Karl  Gerson,'  of  Berlin,  who  suggested  the  use  of  scrotal  ele- 
vating strips.''  These  are  strong  elastic  adhesive  strips  an  inch 
wide,  with  one  margin  softly  fringed.  The  end  of  the  bandage 
has  two  small  linen  tapes.     For  use  the  scrotum  is  grasped  be- 

'  Gerson :  "Elastische  Pflaster-Suspensionsbinden."  Dermatologische 
Centralblatter,  Heft  i v.,  1897;  Berliner  klinische  WocJhenschrift,  No,  3,  1898. 

-The  words  "scrotal  elevating  strips  "are  an  intentional  mistranslation 
of  the  author's  "Suspensionsbinden,"  which  in  a  literal  version  would  cause 
confusion  with  the  accepted  English  designation  of  suspensory  bandages. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHGEA.  65 

]oy,  and  by  compressing  the  sac,  its  contents  are  forced  upward 
to  as  near  the  inguinal  ring  as  possible.  The  bandage,  which 
readily  adheres  to  the  scrotum,  is  tightly  wound  about  it,  Avith 
the  fringed  edge  upward,  to  prevent  abrasion.  When  the  whole 
is  wrapped  about  the  emptied  scrotum,  it  is  firmly  tied  by  the 
linen  tapes.  This  leaves  a  part  of  the  emptied  scrotum  project- 
ing below  the  bandage.  The  ease  with  which  this  manner  of 
treating  epididymitis  can  be  employed,  and  the  facility  with 
which  the  patient  can  reduce  its  pressure,  should  it  become  too 
strong,  are  decided  arguments  in  its  favor.  And  indeed,  in 
many  cases  (perhaps  fifty  per  cent.)  it  acts  quite  satisfactorily. 
In  some,  however,  the  pain  becomes  so  severe  as  to  compel  its 
removal,  and  in  others  it  produces  no  appreciable  effect. 

In  exceptionally  severe  cases  of  epididymitis  or  orcho-epi- 
didj'mitis,  or  when  the  patient  cannot  bear  even  a  touch  of  the 
inflamed  scrotal  contents,  and  when  the  treatment  described  on 
page  69  will  not  afford  relief,  tobacco  poultices  will  assuage 
the  suffering.  These  are  made  of  equal  parts  of  common  smok- 
ing tobacco  and  ground  flaxseed,  boiled  together  and  applied  as 
hot  as  can  be  comfortably  borne.  As  soon  as  such  a  poultice 
begins  to  cool,  a  fresh  one  should  be  applied.  At  night  they 
may  be  substituted  by  the  Casper  ointment. 

While  the  inflammation  is  at  its  height,  some  authors  still 
recommend  crushed  ice  directly  applied  or  used  in  an  ice-bag. 
N^o  relief  is  obtained  by  this  treatment,  which  seems  to  increase 
the  danger  of  abscess.  It  may  be  a  mere  coincidence  that  in 
every  case  I  saw  of  loss  of  the  testicle  from  gonorrhoeal  invasion 
of  the  scrotal  contents,  ice  had  been  employed  during  epididy- 
mitis. 

It  is  ordinarily  held  that  from  the  very  onset  of  epididymitis 
treatment  of  the  urethra  should  be  stopped.  This  idea  is  prob- 
ably due  to  the  usual  diminution  or  entire  arrest  of  the  discharge 
when  epididymitis  begins.  But  in  practice  it  is  found  that 
when  the  physician  desists  from  treating  the  urethra  during 
epididymitis,  its  subsidence  is  followed  by  a  return  of  the  dis- 
charge, usually  far  in  excess  of  the  original  condition ;  while  if 
irrigations  are  persistently  continued  despite  the  epididymitis, 
recurrence  of  the  severe  symptoms  of  gonorrhoea  does  not  take 
place. 

Epispadias  and  Hypospadias,  when  not  so  deforming  the  penis 
5 


66  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

as  to  make  coitus  impossible,  are  jjrone  to  interfere  materially 
witli  successful  irrigations.  It  is  remarkable  tliat  men  with 
very  markedly  deformed  penes  seek  to  gratify  tlie  genesic  im- 
pulse. Tlieir  large  exposure  of  mucous  membrane  makes  tbem 
liable  to  more  ready  infection,  and  in  these  deformities,  the  in- 
genuity of  the  physician  is  often  taxed  for  the  successful  em- 
ployment of  remedial  measures.  Owing  to  sacculations  and 
deviations  produced  by  these  deformities,  gonorrhoea,  despite 
the  best  directed  treatment,  is  prone  to  go  over  into  chronicity. 
The  case  then  is  not  likely  to  be  finally  cured  before  the  urethra 
is  restored  by  plastic  operation. 

Epithelium  in  the  Ueine.— The  only  epithelium  found  in 
normal  male  urine  comes  from  the  bladder.  Louis  Heitzmann, ' 
following  the  principles  laid  down  by  the  lamented  Carl  Heitz- 
mann, asserts  that  in  addition  to  other  microscopic  evidences, 
the  kind  of  epithelium  found  in  the  urine  points  out  the  region 
of  the  pathological  process  going  on  in  the  genito-urinary  tract. 
Fantastic  as  this  is  asserted  to  be,  I  have  almost  daily  evidence 
of  the  parallelism  between  microscopical  and  clinical  diagnosis 
and  always  find  it  a  decided  aid.  The  details  of  the  character- 
istics of  the  various  epithelia,  their  application  to  diagnosis, 
would  lead  beyond  the  scojDe  of  this  little  book.  Moreover, 
they  are  described  by  Heitzmann  so  fully  as,  in  the  light  of  our 
present  knowledge,  cannot  be  improved. 

I  would  like  to  add  an  important  fact  to  his  description  of  the 
epithelia  found  in  the  urine  of  stricture  cases,  even  when  a  path- 
ological coarctation  presents  no  other  evidence  of  its  presence. 
The  urethral  epithelia,  then,  have  among  them  some  thinned 
scales,  with  smoothed  or  faint  nuclei  and  some  without  nuclei. 
These  variations  prove  that  stricture  is  forming  and  persists  as 
long  as  they  are  present.  The  case  must  then  be  treated  by  di- 
latations and  irrigations,  as  detailed  under  chronic  gonorrhoea. 

Eye,  Gonorrhoeal  inflammation  of — see  Ophthalmia,  gonor- 
rhoeal, 

Fia  Waets— see  Condylomata. 

Fistula,  urethral.  Whether  congenital  or  the  result  of  peri- 
urethral abscess  or  of  urethral  rupture  from  stricture,  a  urethral 

1  Heitzmann:  Urinary  Analysis  and  Diagnosis,  William  Wood  &  Co., 
1899. 


COMPLICATIONS   AND   SEQUELJE    OF   GONORRHCEA.  67 

fistula  is  not  likely  to  render  irrigation  especially  difficult,  un- 
less tlie  fistula  is  very  large.  If  situated  in  the  anterior  ure- 
ttra,  it  can  ordinarily  be  covered  by  the  finger  during  irriga- 
tion and  evacuation  of  the  bladder,  when  intravesical  washings 
are  employed.  In  that  case  it  will  be  well  to  have  the  patient 
let  some  of  the  irrigation  fluid  pass  through  the  fistula,  so  that 
its  lining  may  receive  antigonorrhoeal  treatment  at  the  same 
time.  Perineal  fistulse  do  not  usually  offer  much  hindrance  to  ir- 
rigations. If,  however,  they  do,  on  account  of  large  dimensions, 
the  patient  can  be  instructed  to  hold  them  closed  during  irri- 
gation. 

"Floaters,"  in  the  urine.  Macroscopically  visible  sub- 
stances carried  from  the  urethra  by  the  urine  are  among  the 
numerous  genito-urinary  subjects  that  still  merit  much  detailed 
study.  Many  eminent  authors  have  made  painstaking  researches 
regarding  them ;  yet,  until  more  precise  devices  and  methods  are 
employed,  "  floaters  "  in  the  urine  will  remain  but  partially  un- 
derstood as  regards  their  origin  and  special  pathological  signi- 
ficance. 

Their  importance  is  well  brought  into  relief  by  Guiard : ' 

"  It  is  safe  to  say  with  Fiirbringer  that  the  abnormal  products 
contained  in  the  first  portion  of  the  urine  represent  a  more 
constant  symptom  of  goutte  militaire  (morning  drop)  than  the 
drop  itself." 

These  objects  carried  in  the  urine  are  usually  spoken  of  as 
filaments  or  clap  threads  (Tripperfaden)  without  description  of 
any  distinctions  between  their  forms. 

With  a  view  to  a  clinical  outline  of  their  study  I  submit  the 
generic  term  "floaters"  for  all  these  objects,  fully  conscious  of 
its  incompleteness,  as  it  does  not  describe  those,  composed 
essentially  of  pus,  which  sink  to  the  bottom  of  the  glass  con- 
taining fresh  urine. 

Eoughly  it  may  be  said  that  these  floaters  differ  in  size, 
transparency,  consistence,  and  conduct,  according  to  the  sever- 
ity of  the  disease,  its  chronicity,  and  the  progress  of  treatment. 
These  relations,  however,  are  by  no  means  fij-mly  established. 

In  studying  these  floaters,  it  must  be  remembered  that  there 
are  floaters  which  have  no  relation  whatever  to  disease.     These 

'  Guiard  :  Les  Urethrites  ckroniques,  Eueff,  Paris,  1898. 


68 


THE   IREIGATION   TREATMENT   OF   GONORRHCEA. 


vB 


Mm 


have  been  called  normal  mucous  filaments  by  Guy  on.'  The 
first  urine  passed  after  a  night's  rest,  during  which  the  secre- 
tions of  the  mucosa  and  its  glands  have  not  been  washed  away, 
carries  with  it  a  long,  wavy  filament.  At  spots  it  is  rolled  upon 
itself.  It  is  transparent,  occasionally  encloses  minute  air  bub- 
bles, whitish  spots  and  streaks.  It  remains  coherent  on  shak- 
ing the  tube  and  sinks  very 
\r.-  \  slowly  below  the  surface  of  the 

urine.  Its  coherence  is  still 
more  manifest  when  grasped 
by  forceps  or  fished  by  means 
of  a  needle;  when  withdrawn 
from  the  urine  it  stretches  into 
great  length  as  it  is  held  sus- 
pended. 

In  consistence  this  normal 
filament  suggests  the  discharge 
that  comes  from  the  prostate, 
in  that  it  can  be  dragged  about 
upon  a  cover  glass,  maintain- 
ing its  tenuousness  for  a  long 
time.  When  allowed  to  rest, 
it  shows  a  tendency  to  form  a 
colorless,  amorphous  heap. 
As  it  dries  very  slowly,  its 
preparation  for  the  microscope 
is  quite  tedious.  Endeavors 
to  spread  it  with  the  platinum 
loop  result  in  uneven  masses 
interspersed  with  hard  lumps. 
It  is  therefore  best  to  press  it  between  cover  glasses  while 
moving  them  about  upon  each  other  until  an  even  smear  is  ob- 
tained. Even  then,  on  separating  the  cover  glasses,  to  let  the 
specimen  dry  before  flaming,  its  coherence  is  so  great  that  it  is 
likely  again  to  run  together  into  lumps. 

The   specimen  properly  spread,   stains   best  with  alkaline 
methylene  blue.     For  fine  distinction  this  solution  should  not 


Fig.  17.— Normal  Mucous  Filament,  from  a 
healtby  man,  wlio  never  had  urethritis. 
First  morning  urination.  The  mucous  fila- 
ment holds  leucocytes  and  epithelia  in  se- 
ries. X  300  diameters.  (From  Guyon: 
"  Voles  Urinatres,"  vol.  il.,  page  363.) 


1  Guyon :    Legons  cliniques  sur  les  Maladies  des  Voies  urinaires,  tome 
premier,  Baillifere,  Paris,  1894. 


COMPLICATIONS   AND   SEQUELS    OF    GONORRHCEA.  69 

be  over  two  per  cent,  and  left  in  contact  witli  the  specimen  for 
five  minutes  before  washing  it  off. 

On  examination  this  specimen  is  found  to  contain : 

Mucous  threads  and  bands  with  a  tendency  to  curl;  their 
meshes  hold,  isolated,  in  small  groups  or  in  rows : 

Urethral  flat  epithlia  with  small  nuclei ; 

Polyhedric  or  rounded  epithelia  with  large  nuclei ; 

Leucocytes,  often  in  abundance. 

The  normal  filament  never  has  micro-organisms  of  any  kind, 
not  even  the  bacteria  of  the  normal  urethra.  These  bacteria  are 
found  in  secretion  taken  from  the  meatus,  lying  amidst  the  large 
epithelial  cells. 

Not  infrequently  a  healthy  man  learns  that  urethral  filaments 
are  evidence  of  disease.  Unless  the  physician  informs  himself 
thoroughly  of  the  appearance  and  other  characteristics  of  the 
normal  filament,  and  uses  his  knowledge  to  reassure  his  patient, 
the  latter  can  develop  most  obstinate  neurasthenia.  If  not  con- 
vinced of  the  innocuousness  of  these  normal  filaments,  he  may 
get  into  the  hands  of  quacks,  who  by  maltreating  the  healthy 
urethra  with  injections  or  sounds,  will  set  up  an  irritative  ure- 
thritis with  stricture  or  other  complications  in  consequence. 

The  dimensions  and  shapes  of  jpatliological  floaters  in  the  urine 
differ  according  to  the  severity  of  the  disease,  its  duration,  and 
the  results  of  treatment.  These  differences  are  subject  to  most 
marked  variations.  With  a  view  to  establishing  a  basis  of  re- 
cording cases,  and  consequently  their  more  detailed  study,  I 
submit  the  following  classification : 

Sheeds,  coarse,  large,  medium,  small, 
fine. 

Filaments,  coarse,  long,  medium,  short, 
fine. 

Flakes,  coarse  and  fine. 

Granules,  coarse  and  fine. 

In  offering  the  above,  concise  descriptive  terminology  is 
the  sole  object.  It  would  be  remiss  to  omit  from  this  list  the 
comma  filaments,  which,  according  to  Fiirbringer  and  Finger, 
are  moulded  to  the  comma  shape  within  the  prostatic  duct  in 
a  diseased  condition.  When  found,  they  usually  are  emitted 
with  the  last  drops  of  urine. 

The  conduct  and  coherence  of  pathological  floaters  bear  no  re- 


/ 

70  THE   IRRIGATION  TREATMENT   OF   GONORRHCEA. 

lation  to  their  dimensions,  nor  have  they  as  yet  an  established 
position  in  diagnosis.  Guy  on  {op.  cit.),  however,  advises  re- 
taining the  designations  of  pmmlent,  muco-purulent,  and  mucous 
floaters  as  clinical  definitions. 

Purulent  floaters  are  short,  multiple,  opaque,  friable,  are 
easily  broken  up  by  shaking  the  urine,  which  they  render 
turbid.  They  sink  quickly  (drop)  to  the  bottom  of  the  glass 
containing  the  urine. 

31uco-purulent  floaters  3iXe  oii&R  single,  long,  knotted;  some- 
times one  of  their  ends  is  rolled  ui)on  itself  forming  a  sort  of 
head.  They  look  grayish-white  and  have  opaque  dots  or  stripes, 
held  together  by  a  transparent  substance.  They  float  toward 
the  top  or  middle  of  the  urine,  and  cohere  almost  as  much  as 
the  normal  filament  when  withdrawn  for  examination. 

Ilucous  floaters  appear  as  do  those  of  a  muco-purulent  char- 
acter. They  differ,  however,  by  remaining  at  or  near  the  top 
of  the  urine  column  and  in  being  almost  entirely  transparent. 

The  conduct  of  these  floaters  conveys  the  thought  that  there 
exists  a  variance  in  their  specific  gravity — mucus  being  lighter 
than  urine  and  the  floaters  proportionately  heavier — in  accord 
with  the  amount  of  pus  they  contain.  Their  histological  and 
bacteriological  elements  also  contribute  to  the  floating  or  sink- 
ing of  the  floaters.  For  their  study  the  reader  is  referred  to 
works  on  these  subjects.  One  that  embodies  the  most  recent 
views  is  by  Louis  Heitzmann,^  whose  practical  value  for  pur- 
poses of  diagnosis  is  bey ocd  calculation. 

The  examination  of  floaters,  both  macroscopic  and  micro- 
scopic, must  be  made  from  urine  passed  in  the  physician's  ofiice. 
For  this  purpose  the  urine  brought  in  a  bottle  is  worthless,  as 
all  floaters  dissolve  in  a  few  hours. 

Under  appropriate  treatment,  the  shreds  soon  become  broken 
up  into  flakes,  the  long  fllaments  into  shorter  ones,  and  as  the 
disease  nears  its  end,  all  floaters  become  converted  into  granules. 
These  changes  will  be  more  fully  discussed  under  the  treatment 
of  chronic  gonorrhoea. 

Folliculitis — see  Abscess,  follicular  and  peri-urethral. 

Foreign  bodies  in  the  urethra  may  complicate  and  aggravate 
gonorrhoea.     They  may  be  due  to  bodies  inserted  into  the  ure- 

^Heitzmann:  Urinary  Analysis  and  Diagnosis  by  Microscopic  and 
Cliemical  Examination,  William  Wood  &  Co.,  1899. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  Tl 

tlira,  as  has  been  done  in  attempts  to  alleviate  itching  or  tick- 
ling, for  masturbatorj  purpose,  or  by  instruments  breaking  off 
when  introduced  for  therapeutic  objects.  Of  the  articles  in- 
serted to  allay  itching  or  cause  ejaculation,  or  broken  off  dur- 
ing surgical  procedures,  Englisch '  mentions  pins,  bits  of  wood, 
twigs,  grasses,  roots,  sponges,  pipe  stems,  forks,  catheters,  cau- 
tery-carriers, pieces  of  forceps,  etc. 

Concretions  formed  above,  or  fragments  left  in  the  bladder 
after  lithotripsy  may  be  carried  to  the  urethra  and  be  pinned 
fast  there  by  their  sharp  points  penetrating  the  mucosa. 

Foreign  bodies  (stones)  may  also  form  within  the  normal 
urethra ;  they  then  are  usually  located  in  the  fossa,  rarely  ^^ithin 
the  bulb.  They  may  also  be  deposited  in  congenital  or  acquired 
diverticulse  or  fistulse.     They  then  usually  are  uric-acid  stones. 

Foreign  bodies  inserted  or  formed  in  the  urethra  may  be 
carried  upward  by  its  motions  and  those  of  the  bladder.  The 
lengthenings  and  shortenings  of  the  penis  under  varying  emo- 
tions may  mechanically  explain  this  inward  progress.  This, 
of  course,  is  interfered  with  when  the  foreign  body  is  sharp  or 
rough,  causing  its  ingressiou  into  a  consequent  adhesion  to  the 
urethral  wall. 

A  foreign  body  causes  pain  and  the  other  inflammatory 
symptoms  or  an  increase  thereof,  when  these  existed  before  its 
introduction.  Efforts  at  urination,  if  the  body  is  large,  result 
in  forcible  distention  of  the  urethra  behind  it,  while  the  urine 
dribbles  or  drops  from  the  meatus.  If  the  body  is  very  large 
or  not  promptly  removed,  reteiition  may  result,  as  may  also 
abscess  or  extensive  pockets  of  the  urethra. 

Palpation  reveals  the  location  of  the  foreign  body.  Swelling 
about  it  maj'  deceive  the  fingers  regarding  its  size  and  character. 

If  unduly  left  in  the  urethra,  the  urinary  salts  may  form  con- 
cretions about  the  foreign  body. 

The  sudden  establishment  of  localized  pain  within  the  urethra, 
besides  the  other  disturbances,  direct  attention  to  the  possi- 
bility of  a  foreign  body  having  been  introduced,  although  the 
fact  may  be  strenuously  denied  by  the  patient.  This  is  the 
only  circumstance  in  which  urethroscopy  is  justifiable  in  acute 

'  Englisch  :  "Die chirurgischheii Krankheiten  der  mannlichen  Harnrohre." 
Zuelzer  and  Oberlaender's  Klinisches  Handbuch  der  Harn-  xind  Sexualor- 
gane,  vol.  iii.,  Vogel,  Leipzig,  1894. 


72  THE   IRRIGATION   TREATMENT   OP   GONORRHCEA. 

gonorrhoea.  The  paiu  may  be  so  severe  as  to  require  cocaine  or 
eucaine  before  a  tube  can  be  introduced  to  the  site  of  the  foreign 
body.  Great  care  must  be  exercised  to  prevent  the  substance 
■from  being  thrust  farther  into  the  urethra  by  the  obturator.  If 
it  can  be  grasped  through  the  tube  by  the  Guyon  urethral  for- 
ceps, a  dull  curette,  Guyon's  hood  or  an  instrument  improvised 
for  the  x>urpose  to  cover  the  special  needs  of  the  case,  it  may  be 
withdrawn  with  or  through  the  tube,  if  their  relative  sizes  per- 
mit. Whenever  a  rough  or  sharp  body  can  be  drawn  tlirougli 
the  tube,  this  method  is  certainly  preferable,  as  thus  the  ure- 
thra is  protected  from  additional  injuries.  When  the  body  is 
too  large  to  pass  through  the  urethroscopic  tube,  it  must  be 
removed  by  the  most  suitable  of  the  many  instruments  devised 
for  the  purpose.  When  it  is  smooth  and  located  in  the  pendu- 
lous portion,  it  may  be  pressed  out  of  the  urethra  by  careful 
manipulation.  If,  as  occasionally  happens,  a  man  inserts  a  hair- 
pin or  a  hat-pin  into  the  urethra,  their  points  will  bo  found 
presenting  forward.  Efforts  at  removal  are  likely  to  cause  ex- 
tensive gathering  and  penetration  of  the  mucous  folds.  It  will 
be  well,  to  prevent  such  additional  injury  of  whose  extent  the 
surgeon  cannot  judge  at  the  time,  to  cause  the  points  of  such  an 
instrument  to  penetrate  the  urethra  at  the  centre  of  its  floor 
and  to  turn  the  object  by  the  projecting  part  so  that  its  head 
presents  forward.  Then  holding  the  projection  firmly  with 
strong  forceps,  the  penis  is  stripped  backward.to  cause  the  head 
to  project  from  the  meatus,  so  that  it  can  be  grasped  by  another 
forceps  and  withdrawn.  It  is  better  to  thus  risk  a  urethral 
fistula  than  to  produce  internal  injuries  of  the  urinary  channel. 

The  surgeon's  ingeniousness  is  often  severely  taxed  for  the 
removal  of  stones  formed  in  the  urethra.  They  may  be  con- 
tained there  for  a  long  time  without  producing  any  special  dis- 
turbance. Slow  or  sudden  accretions  may,  however,  establish 
increasing  inflammatory  symptoms,  with  local  swelling,  urinary 
infiltration,  formation  of  abscesses  or  diverticulae,  incontinence, 
chills,  fever,  pain  at  the  site  of  the  concretion  or  radiating  pains 
through  the  penis.  If  not  removed,  nature  may  throw  out  the 
stone  through  extensive  ulceration,  producing  large  urinary 
fistulse  which  are  difficult  and  sometimes  impossible  to  repair. 
If  the  stone  or  stones  so  formed  are  left  in  the  urethra,  the  pa- 
tient's life  is  in  danger  from  sepsis. 


COMPLICATIONS   AXD   SEQUELS   OF   GONORRHCEA.  YS 

If  the  stone  cannot  be  removed  through  the  urethra,  external 
urethrotomy  over  it  must  be  performed  as  soon  as  possible. 

Frenum,  short  or  rigid.  While  extreme  degrees  of  this  de- 
formity may  render  erection  painful  and  intromission  impossi- 
ble, it  does  not  safeguard  the  patient  from  acquiring  gonorrhoea. 
It  offers  no  material  interference  with  irrigations ;  still,  while  the 
patient  is  under  treatment,  it  may  be  well  to  slit  the  frenum  to 
correct  the  deformity.  In  case  of  a  timorous  person,  the  little 
operation  may  be  preceded  by  freezing  the  frenum  with  ethyl 
chloride.  The  glans  is  turned  back,  a  narrow  straight  bistoury 
or  tenotome  passed  through  its  base  and  the  frenum  cut  from 
within  outward.  The  cut  may  be  dressed  with  iodoform  or 
nosophen  gauze  and  a  light  bandage  applied  to  keep  the  fore- 
skin retracted  and  prevent  coaptation  of  the  cut  extremities. 

FuNicuLiTis,  —  Inflammation  of  the  spermatic  cord  may 
manifest  itself  while  the  vas  carries  infection  from  posterior 
urethritis  to  the  epididymis  (see  Epididymitis)  or  may  in- 
dependently complicate  gonorrhoea  especially  by  rheumatic 
phlebitis.  It  may  appear  in  the  form  of  serous  funiculitis 
(acute  diffuse  hydrocele  of  the  cord)  or  of  phlegmonous  funicu- 
litis. The  former  shows  itself  as  a  roundish,  sausage-like  swell- 
ing along  the  cord,  which  is  translucent  and  pits  on  pressure. 
Phlegmonous  funiculitis  manifests  itself  in  the  same  shape,  but 
it  is  not  translucent  and  is  very  tender  to  pressure.  From  the 
acuity  of  the  symptoms  it  may  simulate  strangulated  hernia. 
It  is  the  more  dangerous  form,  as  it  may  extend  into  the  peri- 
toneum. 

Acute  funiculitis  in  either  form  is  treated  as  laid  down  under 
the  lighter  form  of  epididymitis.  If  the  manifestations  are  so 
severe  that  the  testicle  is  threatened,  the  funis  should  be  incised 
and  drained. 

Geneeal  Gonoeehceal  Infection. — Some  of  the  complica- 
tions mentioned  here  can  have  their  explanation  only  in  con- 
veyance of  gonococci  through  the  circulation.  P.  Colombini  * 
reports  a  case  which  signally  illustrates  this : 

A  mechanic,  aged  28,  had  acute  gonorrhoea ;  in  two  weeks  he 

'  Colombini :  "Bakteriologische  and  experimentelle  Untersuchungen  liber 
einen  merkwiirdigen  Fall  von  allgemeiner  gonorrhoischer  Infection."  Cen- 
tralblatt  ftir  Bakteriologie,  vol.  xxiv.,  No.  25. 


14:  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

developed  an  inguinal  bubo,  a  week  later  an  abscess  of  the  epi- 
didymis, and  eight  days  after  that,  suppuration  of  the  parotid. 
The  pus  from  all  the  abscesses,  as  well  as  the  blood,  was  found 
to  contain  gonococci,  from  which  pure  cultures  were  obtained. 
Colombini  found  a  boy  of  twenty  who  had  never  had  gonor- 
rhoea and  who  willingly  submitted  to  having  his  urethra  infected 
with  one  of  these  cultures.  A  florid  gonorrhoea  resulted,  which 
required  many  months  of  assiduous  and  patient  treatment  for 
its  cure. 

Thiimmel,'  of  Leipsic,  in  commenting  on  this  case,  says  that 
the  culture  experiments  should  have  sufficed  Colombini  for  cer- 
tainty that  the  diplococci  found  in  the  various  abscesses  and 
blood  were  true  gonococci,  and  that  humane  sentiment  should 
have  forbidden  imperilling  the  health  and  life  of  a  young  man, 
by  so  infecting  him.  Thiimmel  adds  that  if  it  seems  necessary 
to  make  any  such  tests,  the  experimenter  should  use  his  own 
urethra  for  the  purpose — a  sentiment  with  which  all  will  agree. 

In  a  most  explicit  paper,  which  Berg^  read  before  the  Sec- 
tion of  Practice,  New  York  Academy  of  Medicine,  he  recites 
the  details  of  a  case  whose  death,  twenty-nine  days  after  the 
first  symp<'oms  of  a  gonorrhoea,  was  clearly  due  to  systemic 
gonorrhoeal  infection  of  the  heart  and  kidneys  without  any  lesion 
of  the  bladder  or  uretlira.  The  author's  deductions  and  literary 
researches  are  so  instructive  that  justice  to  the  reader  requires 
their  entire  rej)roduction. 

"A  large  number  of  cases  of  ulcerative  endocarditis  com- 
plicating gonorrhoea  have  been  reported.  In  the  larger  number 
of  cases  the  heart  lesion  was  preceded  by  gonorrhoeal  arthritis ; 
thus  Eicord  and  Hunter,  according  to  See,^  believed  that  gonor- 
rhoeal rheumatism  was  sometimes  complicated  by  rheumatic 
endocarditis.  Desnos,  however,  in  1877  performed  the  first 
autopsy  upon  a  case  of  endocarditis  without  rheumatism,  com- 
plicating gonorrhoea ;  and  other  cases  have  since  been  reported 
in  which  arthritis  was  not  present.     Such  a  case  was  reported 

1  Thiimmel :  Centralblatt  ftir  die  Krankheiten  der  Harn-  und  Sexaalor- 
gane,  July  15tli,  1899. 

'■^ Henry  V.  Berg:  "Pyelo-nepliritis  and  Ulcerative  Endocarditis  as  a 
Complication  of  Gonorrhoea — the  Gonococcus  found  in  Pure  Culture  upon  the 
Diseased  Heart  Valve."     Medical  Record,  April  29th,  1899. 

3«Le  Gonocoque,"  1896. 


COMPLICATIONS   AND  SEQUELS   OF   GONORRHCEA.  75 

by  Morel/  That  inflammatory  complications  occur  in  gonor. 
rhoea  lias  always  been  recognized.  Many  of  tliem  are  due  to 
direct  extension  of  tlie  process  from  tlie  uretlira  or  vagina  into 
the  deeper  tissues  connected  witb  these  tracts.  Others  are  the 
result  .of  direct  inoculation  of  distant  structures  with  gonorrhoeal 
pus,  as,  for  instance,  gonorrhoeal  oj)hthalmia.  Neither  of  these 
methods  of  infection  would  account  for  the  production  of  a  gon- 
orrhoeal endocarditis.  Effects  upon  the  nervous  system  and 
the  manifestations  of  general  sepsis  could  be  explained  by  sup- 
posing that  a  toxin  produced  by  the  gonococcus  had  been  ab- 
sorbed iDto  the  lymphatic  and  circulatory  system,  but  the  find- 
ing of  the  gonococcus  in  pure  culture  in  the  vegetations  on  the 
valves  of  a  case  of  ulcerative  endocarditis  complicating  gonor- 
rhoea would  seem  to  prove  that  the  gonococcus  itself  has  been 
carried  to  the  site  of  the  lesion,  and  has  there  produced  the 
ulcerative  manifestation. 

"  For  some  time  it  was  believed,  when  such  an  infection  oc- 
curred, that  it  was  the  result  of  a  mixed  infection.  As  is  well 
known,  the  urethra  is  the  habitat,  even  in  the  normal  state,  of 
numerous  varieties  of  germs,  so  that,  when  the  mucous  mem- 
brane of  the  urethra  has  been  thrown  into  a  pathological  condi- 
tion through  the  action  of  the  gonococcus,  the  pyogenic  germs 
would  find  a  read}^  means  of  entering  the  system  and  producing 
distant  lesions  of  a  septic  character.  Thus  Weichselbaum^  re- 
ports a  complete  autopsy,  with  bacteriological  investigation  of 
a  case,  which  certainly  proved  that  ulcerative  endocarditis  can 
complicate  gonorrhoea  as  a  result  of  mixed  infection,  he  having 
found  gonococci  and  streptococci  upon  the  valves.  A  similar 
case  was  published  by  Ely.^ 

"His*  and  Wilms, ^  although  they  both  published  cases  of 
ulcerative .  endocarditis  complicating  gonorrhoea,  in  which  the 
cocci  found  on  the  diseased  valves  had  morphological  charac- 
teristics of  the  gonococcus,  and  behaved  in  the  characteristic 


1  Th^se  de  Paris,  No.  209,  1878. 

-  Centralblatt  fiir  Bacteriologie,  1887,  2,  and  "  Zur  Aetiologie  der  acuten 
Endocarditis,"  Ziegler's  Beitrage,  1888,  iv.,  3. 
3  Medical  Record,  March  16tli,  1889. 
^Berliner  klinische  Wochenschrift,  1892,  No.  40. 
^Miinclmer  med.  Wochenschrift,  1893,  No.  40. 


76  THE   IRRIGATION  TREATMENT    OF   OONORRHCEA. 

manner  toward  Gram  staining,  yet  considered  tliat  these  cases 
were  the  result  of  mixed  infection. 

"  But  in  the  last  few  years,  particularly  since  1894,  many  ex- 
cellent observers  have  reported  cases  in  which  there  was  found 
at  the  site  of  lesions  complicating  gonorrhoea  only  the  gono- 
coccus.  Thus  Bordone-Uffreduzzi  '  obtained  the  gonococcus  in. 
pure  culture  by  inoculations  made  with  the  fluid  from  a  joint 
affected  by  gonorrhoeal  arthritis.  A  gonorrhoea  was  produced 
in  a  human  subject  by  inoculation  with  the  second  generation 
of  pure  cultures  thus  derived  from  the  arthritic  joint.  Council- 
man" reports  a  case  in  w^hich  he  obtained  pure  cultures,  in  a 
case  of  gonorrhoeal  septicaemia,  from  the  joints,  the  pleura,  the 
pericardium,  and  the  valves  of  the  heart.  Councilman  also 
quotes  a  case  of  Gluzinskyvery  similar  to  the  case  wdiich  my 
communication  recounts,  and  Winterberg^  reports  a  similar 
case.  One  of  the  earliest  cases  of  this  kind  was  that  of  Ley  den,* 
in  which,  as  in  my  case,  the  gonococcus  was  found  after  death. 
Cultures  from  the  blood  during  life,  and  from  the  left  ventricle 
after  death,  remained  sterile. 

"  One  of  the  most  valuable  cases  was  reported  by  Thayer 
and  Blumer.^  In  this  case,  in  addition  to  pure  cultures  of 
gonococcus  found  in  the  valves,  the  blood  cultures  taken  dur- 
ing life  showed  colonies  of  gonococcus  which  would  seem  to 
prove  that  the  gonococci  passed  by  means  of  the  blood  cur- 
rent to  distant  portions  of  the  body,  and  there  gave  rise  to 
infections. 

"  I  think  that  at  present  we  may  believe  that  septic  infections, 
such  as  occurred  in  my  case,  can  be  the  result  of  the  unaided 
action  of  the  gonococcus  distributed  through  the  body  by  the 
blood  channels." 

The  first  conclusive  proof  of  the  gonococcus  causing  peri- 
tonitis was  presented  by  Cushing,^  whose  exhaustive  investiga- 


*  Deutsche  med.  Wochenschrift,  1894,  xx.,  p.  484. 

''Trans,  of  the  Association  of  American  Physicians,  1893,  viii.,  p.  165. 
^Festsch,  zum  25jahr.  Jubil.  d.  Vereins  Deutscli.  Aerzte  zu  San  Fran- 
cisco, 1894,  p.  40. 

*  Berliner  klinische  Wochenschrift,  January  1st,  1894,  xxxii. ,  p.  22. 
^Arch.  de  Med.  experimental.,  November  1st,  1895,  vii.,  No.  6,  p.  701. 
^Harvey  W.  Gushing:  "Acute  Diffuse  Gonococcus  Peritonitis."    Bulletin 

of  the  Johns  Hopkins  Hospital,  May,  1899. 


COMPLICATIONS   AND    SEQUELS    OF   GONORRHCEA.  Y7 

tions  add  evidence  to  the  fact  that  gonorhoeal  processes  are  not 
limited  to  mucous  surfaces. 

Besides  the  joints,  heart,  and  kidney,  the  fourth  ventricle  of 
the  brain  has  been  found  the  seat  of  gonococcal  invasion  through 
the  circulation. 

For  detailed  study  of  the  gonococcus  the  reader  is  referred 
'  to  the  writings  of  the  authors  mentioned,  and  more  particularly 
those  of  Henry  Heimann.* 

Gleet. — This  term  is  used  to  designate  any  kind  of  per- 
sistent discharge  from  the  urethra.  As  it  embraces  no  patho- 
logical or  otherwise  descriptive  import,  it  should  cease  to  have 
a  place  in  medical  nomenclature. 

Gout. — It  is  well  known  that  gout  can  evince  itself  in 
urethritis,  especially  of  the  posterior  urethra,  in  orchitis  and 
epididymitis,  although  these  manifestations  are  rare.  When  a 
gouty  patient  past  middle  age  and  given  to  high  living,  con- ' 
tracts  gonorrhoea,  the  possibility  of  the  constitutional  complica- 
tion should  not  be  left  out  of  mind.  The  urine,  besides  con- 
taining pus,  is  very  acid  and  heavy  with  uric  acid  and  urates. 
Suspicion  is  attracted  to  tJie  possibility  of  a  gouty  diathesis  by 
the  ijresence  of  dry,  scaly  eczema,  tophi,  and  ground-down  teeth. 
In  such  cases  irrigations  must  be  followed  out  as  in  uncompli- 
cated gonorrhoea,  while  the  patient  is  energetically  treated  by 
his  family  physician  for  the  gouty  condition. 

Hemorrhage. — While  bleedings  from  the  meatus  of  other 
than  urethral  origin  would  be  beyond  the  scope  of  this  book, 
their  possibility  must  not  be  left  out  of  consideration  when  they 
occur  with  a  gonorrhoea. 

The  bleedings  from  posterior  urethritis  and  urethrocystitis 
are  discussed  under  their  respective  heads. 

Bleeding  from  the  anterior  urethra  may  be  provoked  by  vio- 
lently employed  strong  injections,  sharp  syringes,  catheteriza- 
tion through  an  acutely  inflamed,  macerated  urethral  mucosa, 
and  the  passage  of  small,  rough  calculi. 

Sometimes  urethral  bleeding  is  provoked  by  coitus  while 
the  patient  has  gonorrhoea,  incredible  as  such  an  act  may  ap- 

1  Heimann :  "A  Clinical  and  Bacteriological  Study  of  the  Gonococcus  Neis- 
ser,"  Medical  Record,  June  22d,  1895.  "  A  Further  Study  of  the  Biology  of  the 
Gonococcus,"  Medical  Record,  December  19th,  1896.  "Further  Studies,  Third 
Series,  on  the  Gonococcus  Neisser,','  Medical  Record,  January  15th,  1898. 


78  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

pear.  S.  Kof mann, '  of  Odessa,  reports  such  a  case.  A  liealtliy- 
looking  individual,  aged  nineteen,  witli  anxious  features,  told 
Kofmann  that  for  over  an  hour  blood  had  been  pouring  from  his 
urethra  in  an  uninterrupted  stream.  The  patient  confessed  hav- 
ing gonorrhoea.  Examination  showed  blood  escaping  from  the 
meatus  in  jets  as  thick  as  a  pencil,  as  from  an  artery  transversely 
divided.  Kofmann  dipped  a  strip  of  gaiize  into  a  solution  of 
alumina  acetate,  mounted  it  on  a  long  button  probe,  carried  it 
as  deeply  as  possible  into  the  urethra  and  packed  it  firmly. 
Then  he  applied  a  pressure  bandage  about  the  i^enis,  ordered 
the  patient  to  go  to  bed,  to  avoid  urinating  as  long  as  possible, 
prescribed  opium  and  forbade  drinking.  On  the  following  day 
the  patient  looked  better,  but  still  considerably  affected.  On 
removing  the  pressure  bandage  and  extracting  the  blood-soaked 
packing,  considerable  bleeding  resulted.  The  whole  dressing 
was  repeated  and  the  patient  ordered  to  return  on  the  following 
day.  He  did  not  do  so  until  one  and  a  half  months  later.  He 
then  related  the  history  of  gonorrhoea  four  years  before,  lasting 
one  3'ear.  Later  he  had  had  chancroid,  still  later  another  gon- 
orrhoea and  chancre,  and  a  third  clap  a  year  before  the  last  con- 
sultation. The  discharge  was  very  copious  and  the  patient 
suffered  much  pain,  especially  on  urinating.  Despite  the  dis- 
ease, the  patient  cohabited  several  times.  During  one  inter- 
course he  experienced  intense  pain,  and  immediately  thereafter 
found  his  linen  blood-soaked  and  blood  dripping  from  the 
meatus.  Since  then  the  bleeding  had  recurred  frequently, 
especially  after  the  abuse  of  stimulants.  The  bleeding  then  al- 
ways came  on  after  passing  clear  urine,  sometimes  in  bright  red 
drops,  sometimes  in  a  stream.  Compression  of  the  penis  for 
some  time  always  arrested  the  bleeding ;  this  was  followed  b}^ 
itching  in  the  urethra,  from  which  the  patient  extracted  a  co- 
agulum  cast  in  the  shape  of  the  channel.  Upon  its  withdrawal, 
bleeding  immediately  recurred.  On  the  day  he  consulted  the 
author  the  patient  had  drunk  several  glasses  of  tea  and  a  con- 
siderable quantity  of  brandy.  Bleeding,  which  then  set  in  upon 
urination,  proved  uncontrollable.  On  the  day  after  the  second 
tamponing  the  patient  removed  the  bandage  and  the  packing. 

1  Kofmann:  "  Zur  Tamponade  der  Urethra."  Centralblatt  der  Chirurgie, 
No.  19,  1899,  quoted  in  Monatsbericlite  iiber  die  Gesammtleistungen  auf  dem 
Gebiete  der  Krankheiten  des  Harn-  und  Sexualapparates,  July,  1899. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  T9 

This  was  followed  by  a  thick  coagulum  and  several  drops  of 
blood.  Then  the  bleeding  stopped ;  the  debility  resulting  from 
the  loss  of  blood  obliged  the  patient  to  remain  in  bed  for  two 
weeks.  The  origin  of  this  bleeding  was  doubtless  gonorrhcBal 
injury  to  a  blood-vessel  deep  in  the  urethra,  with  subsequent 
laceration  of  the  vessel. 

See  also  Foreign  bodies  mid  Traumatism. 

H^MOSPEEHiiA, — Red  or  brownish  semen  is  due  to  the  ad- 
mixture of  blood  dejjendent  upon  very  severe  gonorrhoea  or 
acute  seminal  vesiculitis.  It  is  occasionally  produced  by  mas- 
turbation, chronic  orchitis,  or  chronic  gonorrhoea.  In  vesicu- 
litis the  spermatozoa  are  deformed,  dead,  or  absent.  The 
microscopic  specimens  also  show  red  blood  corpuscles,  pigment, 
granular  detritus,  epithelia  varying  in  accord  with  the  region 
affected,  and  round  cells. 

The  most  aggravated  case  of  hsemospermia  that  ever  came 
under  my  notice  was  that  of  a  man  of  twenty-eight  sent  to  me  for 
complete  loss  of  sexual  desire,  erections,  and  even  nocturnal  emis- 
sions. Six  months  before  he,  for  the  amusement  of  some  com- 
rades of  his  own  intellectual  calibre,  hacl  four  prostitutes  perform 
buccal  masturbation  upon  him  in  immediate  succession.  At  the 
fourth  ejaculation  he  fainted,  and  remained  unconscious  for  a 
long  while.  The  physician  who  was  called  found  blood  oozing 
from  the  meatus.     This  continued  for  several  hours. 

No  pathological  conditions  were  discernible  when  I  examined 
him.  Under  the  use  of  tonics,  galvanism,  faradization  and  the 
psychrophore,  he  undeservedly  recovered  his  potency  in  two 
years. 

For  the  treatment  of  hsemospermia,  see  Vesiculitis  and 
Digital  Palpation  of  the  Urethral  Adnexa. 

Hydrocele. — When  epididymitis,  orchitis,  or  orcho-epididy- 
mitis  complicates  gonorrhoea,  the  extension  of  the  inflammation 
is  not  rarely  accompanied  by  acute  hydrocele.  The  effusion  is 
often  so  slight  as  to  be  barely  perceptible  and,  in  the  majority 
of  cases  is  resorbed,  w4ien  the  local  inflammeiion  subsides  with- 
out any  treatment  being  directed  to  it. 

When  the  swelling  is  very  great  and  produces  much  painful 
tension,  it  is  necessary,  for  purposes  of  differential  diagnosis, 
to  ascertain  whether  it  is  caused  by  serous  effusion.  The  local 
pain,  too  severe  to  permit  manipulation,  is  intensified  when  the 


80  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

patient  is  placed  in  the  standing  position  to  secure  transilla- 
mination  of  the  scrotal  sac. 

In  such  cases,  the  simplified  urethroscope  described  on  page 
190  will  fully  serve,  without  in  any  manner  increasing  the  pa- 
tient's discomfort.  The  light  is  inserted  into  a  large  urethro- 
scopic  tube ;  its  mouth  is  passed  over  the  side  of  the  scrotum 
opposite  the  surgeon's  eyes,  while  the  patient,  whose  testicles 
are  elevated  as  described  under  epididymitis,  is  not  disturbed 
at  all.  If  the  swelling  is  due  to  acute  hydrocele,  the  light  will 
pass  through  the  scrotal  layers  and  the  fluid,  but  not  through 
the  testicle,  whose  body  can  be  clearly  outlined. 

If  the  pain  does  not  yield  to  the  treatment  directed  against 
gonorrhoeal  epididymitis,  relief  may  be  promptly  obtained  by 
puncturing  the  sac  with  a  very  fine  narrow-bladed  knife.  At 
each  withdrawal  of  the  knife,  a  few  drops  of  the  yellowish  effu- 
sion will  squirt  from  the  tumor.  According  to  its  size,  fifteen 
to  fifty  such  punctures  may  be  required.  The  pain  is  trifling,- 
and  the  reduction  of  pain  immediate. 

Consideration  of  hydrocele  as  an  individual  disease,  result- 
ing from  or  preceding  gonorrhoea,  must  be  relegated  to  the 
large,  recent  works  on  genito-urinary  diseases. 

Lymphadenitis  gonokkhceica  (gonorrhceal  bubo)  may  com- 
plicate gonorrhoea  if  the  patient  commits  any  kind  of  excesses, 
indulges  in  violent  or  too  prolonged  exercise,  or  stands  for 
many  hours,  as  book-keepers,  etc.,  must.  Then  one  or  more  of 
the  superficial  glands  in  the  subcutaneous  cellular  tissue,  above 
the  fascia  lata,  and  immediately  below  Poupart's  ligament,  may 
be  affected. 

The  physician  who  makes  it  a  rule  to  examine  his  cases  at 
each  visit,  is  likely  to  discover  and  often  abort  lymphadenitis 
before  the  patient  becomes  conscious  of  it.  The  first  sign  of 
lymphangitis  (see  below)  should  direct  attention  to  the  groin. 
If  a  single  or  double  hard  swelling  is  found  there,  and  even  if  it 
is  not  painful  or  only  slightly  sensitive  to  pressure,  it  should 
be  treated  as  mentioned  below. 

If  the  jjatient's  attention  is  attracted  to  these  glands  bj^pain, 
it  will  be  found  that  the  pain  is  increased  by  pressure  and  by 
standing.  Early  in  the  involvement  of  these  glands,  they  are 
movable  under  the  skin.  Soon,  however,  they  become  adherent 
to  it  and  the  tissues  around  it.     The  region  loses  its  hard  con- 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  81 

tour,  becomes  doughy,  and  assumes  a  reddened  and  later  on  a 
purple  color.  Even  then,  when  properly  treated,  the  inflamma- 
tion may  terminate  in  resolution,  unless  the  patient's  resistance 
is  weakened  by  dissipation,  excessive  work,  malnutrition,  or  a 
"scrofulous  constitution."  Then  the  glands  affected  are  likely 
to  suppurate. 

At  the  first  sign  of  such  glandular  enlargement,  prolonged 
hot  hip-baths,  and  mercurial  ointment  IT.  S.  P.  rubbed  into  the 
region  twice  daily  may  abort  the  case.  Pressure  upon  the  en- 
larged gland,  with  a  well-applied  spica  of  the  groin,  if  the  pa- 
tient must  be  about,  maj^  assist  in  resorption  of  the  swelling.  Its 
effect  may  be  increased  by  neatly  fitting  a  compressed  sponge 
over  the  gland,  and  wetting  it  after  the  spica  is  applied.  If  the 
patient  can  remain  abed,  a  stout  bag  containing  three  to  five 
pounds  of  bird-shot  may  be  fixed  upon  the  groin,  so  that  its 
weight  exercises  continuous  pressure  upon  the  gland. 

If  in  forty-eight  hours  the  above  course  has  not  brought 
about  marked  relief,  the  enlarged  gland  or  glands  should  be 
dissected  out.  Ordinarily  this  can  be  very  well  done  under 
infiltration  anaesthesia  by  Schleich's  method. 

If  the  patient  is  timorous  or  the  physician  of  limited  surgical 
experience,  the  region  may  be  ansesthetized  with  ethyl-chloride 
spray  and  the  enlarged  gland  slit.  After  bleeding  is  arrested 
the  cut  must  be  irrigated  with  hot  water  or  hot  boric-acid  solu- 
tion, and  then  filled  with  antinosin.  This  is  retained  by  a 
covering  of  gauze  and  a  spica.  After  two  or  three  daily  repeti- 
tions of  this  washing  and  dressing,  the  wound  will  be  found 
filled  with  healthy  granulations.  Then  nosophen  dusted  into 
it  and  the  spica  applied  will  ordinarily  result  in  prompt  cicatri- 
zation. 

If  the  case  is  not  seen  until  the  gland  has  become  converted 
into  an  abscess,  evacuation  of  its  contents  must  be  at  once  at- 
tained by  free  incision  and  curetting  the  cavity,  which  then  must 
be  treated  as  above  indicated,  or  by  packing  with  iodoform  or 
nosophen  gauze. 

Lymphangitis. — Persons  who  have  no  idea  of  cleanliness,  or 

those  with  a  tight  meatus,  or  those  employing  dressings  of  the 

glans  that  invite  retention  of  gonorrhoeal  discharge,  are  likely 

to  suffer  inflammation  of  the  lymphatics  of  the  penis. 

At  the  very  inception  one  or  two  superficial,  diffuse,  faint, 
6 


82  THE   IRRIGATION   TREATMENT   OF  GONORRHCEA. 

reddish  lines  show  along  tlie  dorsum  of  the  organ.  Thej  are 
rarely,  if  ever,  observed  bj^  the  patient  in  this  stage.  A  day  or 
two  later  this  discoloration  disappears  and  one  or  two  distinct 
cords  can  be  felt  beneath  the  skin.  These  cords  may  start  near 
the  frenum,  pass  like  a  bridle  upward  and  backward  behind  the 
region  of  the  corona  to  the  dorsum  and  extend  to  the  pubis.  As 
the  skin  over  this  cord  or  cords  becomes  reddened  again,  pain 
sets  in,  which  increases  with  the  thickening  of  the  lymphatics 
involved.  This  pain  is  much  aggravated  during  erection.  With 
the  increase  of  pain,  the  skin  that  was  freely  movable  over  the 
enlarged  lymphatics  sometimes  becomes  adherent  and  very  sen- 
sitive even  to  contact  of  the  clothing. 

In  most  exceptional  cases,  a  spot  anywhere  along  the  dorsal 
lymphatics  hardens,  lies  in  the  loose  connective  tissue,  where 
it  enlarges,  giving  but  little  inconvenience.  The  lymphatics 
beliind  such  a  knot  are  then  not  enlarged.  The  knot  itself 
eyentually  breaks  down  into  an  ordinary  abscess. 

When  a  case  of  gonorrhoea  presents,  showing  the  preliminary 
light  red  lines,  they  subside  after  one  or  two  irrigations,  with 
all  the  precautions  for  cleanliness  described  under  the  technique 
of  irrigation. 

If  thickening  of  the  lymphatics  has  set  in,  in  addition  to 
irrigations,  the  penis  is  kept  enveloped  in  cloths  wet  with  equal 
parts  of  alcohol  and  lead  water,  renewed  whenever  they  begin 
to  get  warm.  Severe  cases  may  require  the  patient  to  keep 
abed,  to  rise  only  for  hot  sitz-baths,  or  entire  hot  baths  three 
or  four  times  daily.  If  erections  are  frequent  and  painful, 
either  monobromate  of  camphor  or  bromide  of  potassium  gen- 
erally controls  them.  These  drugs  failing,  morphine  may  be 
used.  Throughout,  attention  must  be  given  to  free  intestinal 
evacuation. 

If  the  case  has  progressed  to  suppuration,  the  abscess  must 
be  promptly  opened,  curetted,  and  packed  with  iodoform  or 
nosophen  gauze. 

Neuroses  (gonorrhoeal). — While  most  diseases  carry  with 
them  more  or  less  marked  nervous  depression,  there  is  none  in 
which  it  is  more  evident  or  more  frequent  than  gonorrhoea.  The 
cause  of  nervous  manifestations  even  at  the  inception  of  clap 
may  be  attributable  to  the  consciousness  of  being  physically 
unclean,  or  of  being  a  menace  to  others;  or  they  may  be  at- 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHOEA.  83 

tributable  to  the  deprivation  from  habitual  sexual  intercourse 
or  stimulants.  More  recent  investigations,  however,  make  it 
appear  that  the  gonococcus  toxins  directly  attack  the  nervous 
system.  At  all  events  Leleneff '  reports  the  following  disturb- 
ances of  the  nervous  sj^stem  produced  by  gonorrhoea : 

(1)  Changes  in  the  sensory  nerves,  causing  anaesthesia, 
hypersesthesia,  paraesthesia,  and  pain  in  the  nerves,  in  the  skin, 
in  joints,  in  muscles,  and  in  internal  organs ;  (2)  changes  in 
the  vasomotor  nerves,  causing  hyperemia,  anaemia,  paralysis  of 
vessels,  and  dermographism;  (3)  changes  in  the  secretory 
nerves,  causing  increased  or  diminished  sweating,  local  sweat- 
ing, an  increase  in  the  flow  of  mucus  from  the  urethra,  etc. ;  (4) 
changes  in  the  trophic  nerves,  causing  some  forms  of  skin  dis- 
ease, atrophy  of  the  testicle,  and  muscular  atrophy ;  (5)  changes 
in  the  motor  nerves,  causing  paresis,  paralyses,  and  twitchings; 
(6)  changes  in  the  skin  reflexes  and  tendon  reflexes.  Gonor- 
rhoea! affections  of  the  central  nervous  system  give  rise  to  a 
variety  of  symptoms,  such  as  asthenic  neuropsychosis,  neuras- 
thenia, hemiplegia  phenomena,  etc. 

-  These  disturbances,  however,  seem  to  premise  that  gonor- 
rhoea, to  produce  them,  must  be  implanted  upon  an  existing 
neurotic  tendency.  Beard '^  has  shown  that  Americans  are  more 
prone  to  this  complication  than  are  patients  of  other  nationali- 
ties. He  attributes  this  to  our  unfavorable  climate,  overwork, 
anxiety,  excesses  in  tobacco  and  alcohol. 

This  view  is  confirmed  by  my  observations  in  European 
genito-urinary  dispensaries  and  hospitals,  where  neurasthenia 
complicating  gonorrhoea  is  certainly  far  less  frequent  than  it  is 
among  us. 

Von  Krafft-Ebing^  reports  only  eight  cases  in  which  local 
genito-urinary  disease  was  manifest  in  one  hundred  and  four- 
teen cases  of  neurasthenia. 

Lowenf eld  *  is  of  the  opinion  that  most  of  those  afflicted  with 


1  Leleneff:  "The  Nervous  System  in  Gonorrhoea."    Wratch,  No.  4, 
escei'pted  by  Medical  Record,  July  15th,  1899. 

2 Beard:  "Sexual  Neurasthenia." 

^Von  Krafft-Ebing  :  "  Ueber  Neurasthenia  Sexualis  beim  Manne."    Wie- 
ner medicinische  Presse,  No.  5  et  seq.,  1887. 

^Lowenfeld:    "Sexualleben  und  Nervenleiden,"  Bergmann,  Wiesbaden, 
1899. 


84:  THE   IRRIGATION   TREATMENT   OF  GONORRHCEA. 

clap-neurasthenia  are  individuals  witli  hypocliondriacal  predis- 
position, in  whom  the  consciousness  of  suffering  from  a  genital 
affection  evokes  persistent  mental  depression  and  frequently 
most  exaggerated  worry  regarding  its  possible  consequences. 
Such  a  patient  continually  directs  his  thoughts  to  the  condition 
of  his  urethra,  watches  its  secretions  with  anxious  care,  and  sub- 
mits to  interminable  attempts  at  curing  it  with  astringents  and 
cauterizants.  This  author  concludes  that  clap-neurasthenia  is 
more  frequently  the  result  of  chronic  maltreatment  of  the  ure- 
thra than  of  its  disease. 

Every  practitioner,  and  particularly  every  specialist,  has  seen 
innumerable  cases  in  which  urethritis  has  been  maintained  in- 
definitely by  over-treatment,  even  when  the  methods  employed 
correctly  met  the  indications  while  the  disease  existed. 

Naturally  then,  when  discharge  and  floaters  in  the  urine  are 
made  to  continue  by  urethral  maltreatment,  or  continuance  of 
treatment  when  it  has  become  unnecessary,  the  neuroses  pro- 
voked by  the  manifestations  of  apparent  disease  must  continue. 
The  more  persistent  these  neuroses  are,  the  more  difficult  their 
cure  becomes. 

When  all  discharge  has  ceased,  the  presence  of  floaters  in 
the  urine,  which  may  continue  for  several  weeks  after  a  gonor- 
rhoea has  subsided,  may  disturb  the  patient's  mind.  Some 
patients,  even  when  the  urine  is  perfectly  clear,  acquire  remark- 
able dexterity  in  stripping  the  urethra,  by  which  they  can  at 
almost  any  time  produce  a  minute  drop  of  normal  secretion  at 
the  meatus,  to  which  they  point  as  evidence  of  their  uncured 
condition. 

When  in  such  cases  the  urethroscope  shows  the  absence  of 
disease,  it  is  the  physician's  duty  to  direct  his  treatment  to  the 
mental  condition,  lest  the  patient  be  driven  by  its  persistence 
to  the  quacks,  who  will  gratify  the  patient's  desire  for  active 
local  maltreatment  as  long  as  he  can  pay  for  it.  Arguments 
and  evidence  of  the  microscope  are  only  exceptionally  of  avail. 
The  more  palpable  the  physician's  honest}'  is,  the  less  he  will 
be  able,  as  a  rule,  to  convince  such  a  patient  that  the  healthy 
urethra  must  be  left  alone. 

Under  such  circumstances,  it  is  perfectly  justifiable  to  per- 
suade such  a  patient  that  the  passed  gonorrhoea  has  affected  his 
constitution  and  that  he  requires  constitutional  treatment  for 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHOEA.  85 

its  cure.  Ordinarily  tlie  drugs  administered  must,  to  be  effec- 
tive, have  a  decided  taste,  sucli  as  tincture  of  nux  vomica  in 
watery  solution.  It  will  be  well  to  warn  sucli  patients  against 
tlie  disastrous  effects  of  "  squeezing  out  tlie  perennial  drop " 
wLile  taking  this  drug  or  any  other  that  may  be  used.  (See 
also  Chronic  Gonorrhoea.) 

If  the  neurasthenia  persists  despite  all  suggestive  treatment 
that  the  physician's  ingenuity  may  devise  to  suit  the  special 
manifestations  in  each  case,  or  the  peculiar  bent  the  mind  has 
taken,  the  patient  should  be  referred  to  a  neurologist,  because 
then  it  has  gone  beyond  the  field  of  general  practice  or  the 
genito-urinary  specialty. 

It  must,  however,  never  be  forgotten  that  a  very  minute  ure- 
thral lesion  can  maintain  a  neurotic  condition,  even  when  not 
the  slightest  discharge  can  be  brought  to  the  meatus  and  the 
urine  remains  perfectly  clear.  If  such  a  lesion  exists,  it  can  be 
found.  When  it  is  properly  treated,  the  neurasthenia  subsides 
with  or  shortly  after  its  disappearance. 

When  gonorrhoea  has  destroyed  tissues  or  organs  through 
changes  in  the  trophic  nerves,  surgical  intervention  may  be  re- 
quired, to  restore  the  patient's  nervous  and  mental  equilibrium. 
Several  cases  are  reported  in  which  an  atrophied  testicle  was 
substituted  by  a  celluloid  body,  with  satisfactory  results,  as  far 
as  the  patient's  mental  state  was  concerned. 

(Edema  of  the  skin  of  the  penis  may  complicate  gonorrhoea, 
especially  in  persons  who  keep  the  organ  in  a  filthy  condition. 
It  subsides  with  attention  to  cleanliness. 

In  a  number  of  cases,  an  immense  oedema  of  all  the  tissues 
of  the  penis  sets  in  almost  immediately  after  the  first  or  second 
irrigation.  This  is  painless  and  disturbs  the  patient  in  no  wise, 
except  by  the  sensation  of  a  large  bulk  in  the  trousers.  In  the 
majority  of  cases,  when  this  oedema  occurs,  the  gonorrhoea  will 
be  aborted  in  a  very  short  time,  probably  because  then  no  parts 
of  the  organ  remain  a  favorable  culture  medium  for  gonococci. 

Ophthalmia,  gonorrhoeal. — Whenever  a  patient  with  gonor- 
rhoea, or  one  who  has  come  in  contact  with  the  disease,  shows  a 
slight  reddening  of  the  conjunctiva,  with  an  increased  flow  of 
tears,  the  latter  should  be  examined  microscopically.  Whether 
gonococci  are  found  or  not,  the  patient  should  without  a  mo- 
ment's loss  of  time  be  referred  to  an  ophthalmologist. 


86 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


If  a  specialist  in  eye  diseases  is  not  instantly  accessible,  tlie 
patient  should  be  put  to  bed  and,  until  the  ophthalmologist 
arrives,  small  compresses  taken  from  a  block  of  ice  must  be  put 
upon  the  eye,  every  two  or  three  minutes,  day  and  night. 

Silver  nitrate,   as  laid  down  in  works  on  ophthalmology, 
should  be  employed  as  soon  as  the  secretion  becomes  creamy. 
The  healthy  eye  should  be  protected  by  an  occlusive  dressing. 
BuUer's  dressing  has  the  advantage  of  permitting  continual  in- 
spection  and    conse- 
-'^^^,  quent    early    treat- 

ment, if  the  healthy 
eye  has  become  in- 
fected. 

OeCHI  -  EPIDIDYMI- 
TIS —  see  Epididy- 
mitis. 

Pabaphimosis 
complicating  gonor- 
rhoea does  not  fre- 
quently assume  a 
severe  form,  and  it 
usually  subsides  as 
the  gonorrhsea  im- 
pr  o  ves  .  When, 
however,  a  patient 
attempts  forcibly  to 
reduce  a  gonorrhoeal 
phimosis  and  man- 
ages to  slip  the  fore- 
skin beyond  the  glans,  the  preputial  orifice  soon  becomes  rigid, 
constricts  the  penis,  which  then  swells,  producing  the  familiar 
deformity.  If  the  constriction  and  consequent  oedema  are  not 
promptly  relieved,  the  penis  presents  three  distinct  swellings 
and  three  more  or  less  deep  contractures,  as  shown  on  the  ac- 
companying drawing. 

1.  The  margin  of  the  corona  is  much  swollen,  forming  a 
thick  ridge. 

2.  The  coronary  sulcus  rendered  deeper  by  the  swelling 
around  it. 

3.  Glistening  mucous  fold  sometimes  overlapping  the  sulcus 


Fig.  18.— Paraphimosis. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  8Y 

and  glans,  formed  of  tliat  part  of  the  preputial  mucosa  that  lay 
upon  the  posterior  aspect  of  the  corona. 

4.  A  very  deep,  tight,  constricting  band;  this  is  the  pre- 
putial cutaneo-mucous  margin,  and,  being  the  real  point  of  con- 
striction, is  the  cause  of  the  trouble  in  this  position.  Ifc  is  the 
surgical  point  of  paraphimosis,  the  one  that  must  be  severed 
when  operation  becomes  necessary. 

5.  Behind  the  hard  constriction  is  another  thick  roll,  con- 
sisting of  preputial  integument  crowded  back  and  held  there  by 
the  constriction. 

6.  Another  furrow,  less  deep  and  less  tight  than  the  former, 
is  formed  by  the  swollen  tissues  crowding  back  upon  those  that 
are  not  involved  in  the  constriction  before  them. 

This  general  type  of  paraphimosis  may  suffer  a  number  of 
variations :  the  rolls  of  mucosa  and  skin  may  become  so  thick 
as  to  cover  the  furrows  beneath  them ;  the  penis  may  be  so  con- 
stricted at  the  second  furrow  as  to  make  it  look  as  if  bent  for- 
ward at  a  right  angle  upon  itself;  the  constriction  may  be  lateral, 
giving  the  penis  a  twisted  appearance. 

-  When  dislocation  backward  of  the  prepuce  is  recent,  it  may 
often  be  reduced  by  manipulation,  after  soaking  the  penis  in  a 
hot  antiseptic  solution  for  twenty  or  thirty  minutes.  Then, 
after  drying  the  organ,  a  little  vaseline  or  lubrichondrin  is  ap- 
plied within  the  second  constricting  furrow,  but  nowhere  else, 
lest  it  render  the  organ  too  slippery  for  manipulation.  The 
penis  is  then  grasped  and  steadied  by  the  index  and  middle 
fingers  of  both  hands,  passed  from  both  sides  so  that  the  tips 
of  the  indices  touch  each  other  on  the  dorsum,  while  the  middle 
fingers  cross  below.  In  this  position  the  fingers  compress  the 
third  roll,  while  the  thumbs  perform  a  species  of  massage  upon 
the  glans  as  they  strive  to  crowd  it  back  within  the  prepuce. 
If  it  will  yield  at  all,  it  will  do  so  in  a  few  minutes  of  this 
manipulation. 

If  the  paraphimosis  cannoi  be  reduced  by  manipulation,  or 
if  efforts  to  perform  it  are  excessively  painful,  or  if  the  constric- 
tion has  become  too  dense  to  yield,  it  will  be  promptly  relieved 
by  incision  in  most  cases. 

Neglected  cases  usually  end  by  necrosis  at  the  central  dorsal 
point  of  the  second  furrow.  Following  this  indication,  the 
surgeon  passes  a  sharp-pointed,  curved,  narrow  bistoury  be- 


88  THE   IRRIGATION   TREATMENT   OP   GONORRHOEA. 

neath.  tlie  constriction,  gathering  it  npon  its  edge  as  if  it  were 
a  cord.  In  doing  so,  he  takes  care  not  to  wound  the  corpora 
cavernosa.  In  severing  the  "cord "  it  may  impart  quite  a  carti- 
laginous sensation  to  the  knife.  If  the  first  cut  is  not  successful 
in  relieving  the  tension,  a  second  may  be  made. 

In  case  the  swelling  so  overlaps  or  distorts  the  furrows  that 
the  second  one  cannot  be  found,  a  straight,  narrow  knife  is  used 
instead  of  a  curved  one.  The  penis  is  then  rested  in  the  palm 
of  the  left  hand  while  the  thumb  and  fingers  depress  and  render 
tense  the  folds.  Then  the  skin  and  mucous  membrane  are 
incised  firmly,  holding  the  knife  perpendicularly'  to  the  axis  of 
the  penis,  but  not  cutting  more  deeply  tha.n  the  integumentary 
coverings.  These  incisions  must  be  continued  until  the  con- 
striction is  felt  to  give  way.  In  such  case  the  incisions  along 
the  dorsum  of  the  penis  should  be  no  longer  than  the  length  of 
the  glans. 

When  the  constriction  has  been  severed,  the  foreskin  can  as 
a  rule  be  easily  drawn  forward.  It  will  then  appear  as  if  it  had 
been  slit.  Ordinarily  the  cut  heals  soon,  leaving  a  dog's-ear 
foreskin,  which  subsequently  may  be  remedied  by  complete  cir- 
cumcision. 

Peeiaetheitis — see  Rheumatism. 

Phumosis. — While  many  fine  distinctions  are  made  by  au- 
thors regarding  irretractibility  of  the  foreskin,  Taylor's'  defini- 
tion embraces  all  practical  requirements:  "Phimosis  is  that 
condition  of  the  prepuce  which  prevents  its  retraction  and  the 
exposure  of  the  glans.     It  may  be  congenital  or  acquired." 

Many  boys  are  born  with  a  redundant  prepuce.  With  some 
it  is  so  tight  that  it  cannot  be  withdrawn.  It  is  debatable 
whether  any  boys  are  born  with  adhesions  of  the  prepuce  to  the 
glans ;  at  all  events,  in  most  of  those  whom  I  have  circumcised, 
the  prepuce  had  at  least  a  few  adherences.  In  some  the  adher- 
ence was  so  general  as  to  oblige  complete  dissection  of  the 
inner  lining  from  the  glans. 

The  growth  of  the  prepuce  sometimes  does  not  keep  pace 
with  that  of  the  rest  of  the  organ.  The  result  may  be  an  arrest 
of  development  of  the  glans.  In  one  case  treated  in  my  class 
in  the  New  York  School  of  Clinical  Medicine,  the  patient,  a 

'Taylor:  Venereal  Diseases,  Lea  Brothers  &  Co.,  Philadelphia,  1895. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.  89 

negro,  aged  thirty-eight,  had  a  fully  developed  penis,  except  as 
to  the  glans,  which  was  no  larger  than  that  of  a  small  boy  of 
twelve  years.  After  liberation  of  the  glans  by  circumcision  of 
a  very  small,  tight,  thick,  unyielding  foreskin,  the  glans  began 
to  develop  and  in  three  months'  time  attained  almost  its  normal 
dimensions. 

A  tight  foreskin,  even  when  not  redundant,  by  its  irritation 
is  likely  to  provoke  masturbation.  Normal  secretions,  or  drops 
of  urine  retained  and  decomposed  within  the  preputial  sac,  may 
cause  ulcerations  and  heavy  strong  adhesions  whenever  these 
ulcerations  heal.  Concretions  of  smegma,  sometimes  quite  hard 
and  friable,  are  often  found  lying  about  the  glans,  and  especially 
in  the  coronary  sulcus.  Urinary  salts  are  sometimes  deposited 
in  this  region.  All  these  substances  act  as  foreign  bodies  erod- 
ing the  delicate  mucosa ;  by  accretion  they  may  become  adherent, 
embedded,  and  often  produce  extensive  ulcerations. 

Local  symptoms  of  phimosis  may  be  entirely  absent,  the 
mucosa  accustoming  itself  to  the  irritation  even  of  inspissated 
pieces  of  smegma  or  urinary  concretions.  They  then  will  be 
discovered  only  accidentally  or  when  an  infection  obliges  the 
patient  to  seek  professional  advice.  Ordinarily,  however,  there 
is  at  least  heat  about  the  glans.  More  frequently  all  the  local 
evidences  of  balanitis  or  balanoposthitis  with  their  conse- 
quences— new  adhesions,  venereal  warts  and  fissures — call  for 
treatment. 

Phimosis  may  lead  to  obstructive  conditions  due  to  the  ad- 
hesions, retained  secretions,  or  subpreputial  calculi  mentioned 
above,  or  the  preputial  orifice  may  be  so  tight  as  to  prove  an 
obstruction  to  the  free  emission  of  urine.  Then  vesical  irrita- 
bility, dilatation  of  the  bladder,  ureters,  and  renal  pelvis  may 
obtain.  Hemorrhoids  and  hernia  may  also  result  from  the 
heavy  pressure  required  in  attempts  to  force  the  urine  through 
the  obstacles. 

The  liberal  supply  of  nerves  to  the  glans,  when  pressed 
upon  by  a  tight  foreskin  and  its  local  results,  often  reflexly 
evokes  diseases  such  as  convulsions  in  children,  urinary  re- 
tention and  incontinence,  unduly  frequent  erections,  excessive 
seminal  emissions,  spastic  paralyses,  pseudo-hip-joint  disease, 
muscular  incoordination,  etc.  Naturally  their  presence  with  or 
developing  in  a  phimosed  patient  does  not  make  the  tight  fore- 


90 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


skin  the  only  etiological  factor;  still,  its  possibility  must  not 
be  overlooked. 

When  phimosis  develops  from  neglected  gonorrhoea,  it  ordi- 
narily subsides  shortly  after  beginning  irrigations,  unless  heavy 


Fig.  19.— Applying  Constrictor. 


lymph  deposits  have  organized  in  the  preputial  tissues.  In 
such  cases,  or  when  phimosis  precedes  gonorrhoea,  circumcision 
should  be  performed  as  soon  as  the  more  acute  symptoms  have 
subsided.  But  when  the  preputial  orifice  is  so  small  as  to  pre- 
vent exposure  of  the  meatus,  or  when  adhesions  are  so  numerous 
and  tight  that  the  glans  cannot  be  cleansed,  circumcision  will 
be  required  despite  the  acute  gonorrhoea. 

The  objections  that  may  be  offered  to  circumcision  during 
acute  gonorrhoea  are : 

1.  Possible  infection  of  the  wound,  especially  when  the  ure- 
thritis is  of  a  mixed  character. 

2.  Difficulty  of  manipulation  of  the  penis,  as  in  irrigations, 
before  th^ircumcision  wound  has  healed. 

To  prevent  infection  of  the  cut,  as  far  as  possible  while  the 
patient  has  acute  clap,  a  continuous  stream  of  mercuric  bichlo- 


COMPLICATIONS    AND   SEQUELS    OF   GONORRHCEA. 


91 


ride  1 :  30,000  should  be  kept  running  over  tlie  entire  field  of 
operation,  from  its  beginning  to  its  end. 

The  other  objection  is  easily  overcome  by  the  circumcision 
I  invariably  practise,  which  may  be  concisely  described  in  the 
following  directions : 

1.  Thoroughly  scrub  the  penis,  and  especially  as  much  of 
the  mucous  fold  of  the  prepuce  as  can  be  reached,  with  soap 
and  hot  water. 

2.  Irrigate  the  preputial  sac  with  hot  potassic  permanganate 
solution  1 : 6,000  until  the  fluid  that  flows  from  it  is  entirely 
clear. 

3.  Envelop  the  anterior  four-fifths  of  the  penis  in  absorbent 
cotton  soaked  in  mercuric  bichloride  1 : 2,000. 

4.  Tie  a  rubber  band  as  tightly  as  it  can  be  drawn  around  the 
root  of  the  penis  (Fig.  19).    As  brutal  as  this  precaution  against 


Fig.  20.— Freezing  Tip  of  ForesMn. 

hemorrhage  may  appear,  it  is  quite  painless,  and  its  only  result 
is  some  ecchymosis  of  the  penis,  which  subsides  in  a  few  days. 
5.  Pass  a  probe  as  large  as  the  preputial  orifice  will  admit 
into  the  sac  and  sweep  it  around  all  its  parts  to  ascertain  if  the 
prepuce  is  anywhere  adherent. 


92  THE   IRRIGATION   TREATMENT   OF    GONORRHCEA. 

6.  Freeze  a  small  spot  at  the  tip  of  tlie  foreskin  with  ethyl 
chloride  (Fig.  20). 

7.  Inject  into  the  frozen  spot  a  drop  of  Schleich's'  solution 
No.  1  ^ig.  21). 

8.  At  the  posterior  margin  of  the  bleb  so  produced  inject 
another  drop  within  the  skin.     Continue  the  line  of  drops  along 


Fig.  31,— Injecting  First  Drop  of  AnfEsthetic  Solution. 

the  dorsal  aspect  of  the  prepuce  to  a  quarter  of  an  inch  beyond 
the  point  where  the  elevated  margin  of  the  corona  is  felt  through 
the  foreskin. 

9.  Inject  a  similar  line  of  drops  following  the  line  of  the 
coronary  margin  until  the  region  of  the  frenum  is  reached  on 
one  side.     Repeat  this  procedure  on  the  other  side. 

10.  Keep  the  syringe  loaded  for  more  infiltration,  especially 
when  the  preputial  orifice  is  so  tight  that  the  mucosa  cannot 
be  exposed. 

11.  Pinch  up  the  dorsal  aspect  of  the  prepuce  with  the  left 
thumb  and  index  finger. 

12.  Insert  the  blunt  arm  of  a  pair  of  probe-pointed  scissors 
and  carry  it  back  as  far  as  possible  toward  the  corona.  Drop  the 
prepuce  upon  the  blade  of  the  scissors ;  inexperienced  operators 

'  Schleich  :  Schmerzlose  Operationen,  Springer,  Berlin,  1894. 


COMPLICATIONS   AND    SEQUELJE   OP   GONOKRHCEA. 


93 


will  do  well  to  sweep  the  scissors  about  under  tlie  foreskin, 
while  the  left  fingers  feel  it,  especially  in  infants,  to  be  sure  that 
the  scissors  arm  is  not  within  the  urethra  (Fig.  22). 

13.  Draw  back  the  skin  and  thus  render  it  as  tense  as  possi- 
ble. Cut  through  the  part  of  the  foreskin  that  lies  between  the 
scissors  blades.  This  will  produce  a  large  cut  through  the  skin 
and  a  disproportionately  small  cut  into  the  mucosa  (Fig.  23). 

14.  Grasp  the  cut  angles  of  the  skin  and  mucosa  with  artery 
clamps,  hold  one  in  the  left  hand  and  give  the  other  to  an  as- 
sistant. "While  the  mucosa  is  thus  tensely  held,  infiltrate  drops 
of  the  Schleich  solution  along  the  mucosa  as  far  as  possible  in 
a  line  toward  the  corona.  Cut  the  mucosa  as  far  as  this  line 
goes.     Eepeat  the  linear  infiltration  in  the  part  that  is  now  ex- 


FlG.  23.— Inserting  Scissors. 


posed.     Continue  cutting  and  infiltrating  to  within  three-eighths 
of  an  inch  of  the  corona. 

15.  Repeat  the  entire  procedure  along  the  lateral  lines  reach- 
ing from  the  dorsum  of  the  prepuce  to  the  frenum,  on  both 
sides,  leaving  a  collar  of  mucosa  three-eighths  of  an  inch  wide. 
Let  the  prepuce  then  hang  from  the  region  of  the  frenum,  to 
serve  as  a  convenient  handle  for  further  manipulations  (Fig.  24). 


94 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


No  bleeding,  beyond  a  slight  oozing,  will  interfere  with  the 
above  steps,  if  the  rubber  band  about  the  root  of  the  penis  has 
been  firmly  applied.  Should  bleeding  to  a  disturbing  extent  set 
in,  another  and  tighter  band  around  the  root  of  the  penis  will 
remedy  the  defect,  or  the  bleeding  vessels  may  be  ligated. 

16.  Pass  a  needle  armed  with  six  inches  of  0  or  00  catgut 
through  the  mucosa,  at  the  centre  of  the  dorsum  of  the  penis. 
A  straight  Gentile's  (Fig.  26)  modification  of  the  Hagedorn 
needle  will  be  found  admirable  for  quick  work.     The  needle 


Fig.  33.— First  Dorsal  Incision. 


should  transfix  the  mucosa  at  one-eighth  inch  from  its  cut  margin. 
Take  up  the  skin  in  the  same  manner  and  tie  the  skin  and  mu- 
cosa into  neat,  tight,  but  not  wrinkled  apposition,  with  a  double 
surgical  knot.  Take  care  that  the  cut  edges  of  skin  and  mucosa 
embrace  no  cellular  tissue.  Grasp  the  free  ends  of  the  catgut 
in  the  jaws  of  an  artery  forceps  and  lay  it  on  the  abdomen  which 
has  been  covered  with  a  sterilized  towel.  This  will  serve  to 
readily  distinguish  it  from  the  other  sutures  at  the  close  of  the 
operation. 

17.  Apply  similar  sutures,  each  six  inches  long,  to  bring  skin 
and  mucous  membrane  together  around  the  entire  cut  edges> 


COMPLICATIONS   AND   SEQUELS   OF   GONOKKHGEA.  95 


Fig.  24. — Lateral  Incision. 


until  within  one-fourth  inch  of  each  side  of  the  frenum.  Always 
take  care  that  no  connective  tissue  is  allowed  to  project  between 
the  lips  of  the  wound,  which  would  then  not  have  the  advantage 


Fig.  25.— Inserting  the  First  (Dorsal)  Suture. 


96 


THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 


5 


of  primary  union.      Wlierever  a  bit  of  this  tissue  cannot  be 

forced  back  to  remain,  another  suturing  of  skin  to  mucosa  over 

it  will  accomplish  the  desired  end.     After  knotting  each  suture 

at  the  wound  lips,  tie  its  free  ends  together  in  a 

slip  knot  so  that  each  pair  of  sutures  can  be  easily 

found  together  at  the  conclusion  of  the  operation. 

18.  Baise  the  prepuce  where  it  hangs  from 
the  freuum  and  replace  the  skin  and  mucosa  in 
their  original  relative  positions.  "While  an  assist- 
ant so  stretches  the  foreskin,  pierce  its  base  along 
the  frenum  with  a  needle  armed  with  sis  inches  of 
catgut  twice  the  thickness  of  that  used  before. 

19.  Give  the  ends  of  the  suture  to  the  assistant 
who  stretches  it  at  a  tangent  to  the  axis  of  the 
penis.  Take  the  prepuce  in  the  left  fingers,  rais- 
ing the  penis.  Then,  avoiding  the  suture  held 
by  the  assistant,  cut  off  the  foreskin  neatly  along 
the  line  of  the  frenum.  Tie  the  ligature  to  bring 
the  skin  in  coaptation  with  the  exposed  part  of 
the  cut  frenum.  Grasp  the  ends  of  the  suture 
with  an  artery  clamp,  and  place  it  upon  the  scro- 
tum, which  has  been  covered  with  a  sterilized  towel. 

20.  Examine  the  entire  line  of  sutur^,  to  be 
sure  that  neat  coaptation  is  everywhere  obtained. 
Wherever  connective  tissue  projects  between  the 
lips  it  must  be  returned,  and  if  it  will  not  remain 
beneath  the  lips,  an  additional  suture  placed  over  it. 

21.  Slowly  relax  the  rubber  band  that  con- 
stricts the  root  of  the  penis.  In  a  few  moments 
there  may  be  some  oozing  from  the  lips  of  the 
wound.  If  more  than  mere  oozing  results,  addi- 
tional sutures  will  control  the  bleeding. 

22.  Fold  a  strip  of  ten-per-cent.  iodoform  gauze 
or  three-per-cent.  nosophen  gauze,  eight  inches  long 
by  one  and  one-half  inches  wide,  into  four  smooth, 
equal,  longitudinal  folds.     Have  it  stretched  by 

the  assistant  (Fig.  30)   at  right  angles  over   the  first  suture, 

whose  ends  are  held  by  the  artery  clamp  lying  on  the  abdomen. 

23.  Release  the  suture  from  its  clamp,  separate  its  ends,  and 

pass  them  around  the  gauze.     Tie  the  gauze  firmly  against  the 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  97 


Fig.  28.— Lateral  Sutures  Applied. 


98 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


first  knot,  by  wliicli  the  skin  and  mucosa  were  brought  together, 
Repeat  this  procedure  with  each  suture,  whose  corresponding 
ends,  though  now  all  are  matted  together  with  blood,  can  be 
easily  found,  because  they  were  tied  together  with  a  slip-knot. 
The  gauze  must  everywhere  be  laid  smoothly  upon  the  wound 
lips ;  its  tension  must  be  even. 

24.  When  both  ends  of  the  gauze  are  hanging  from  the  last 
suture  at  either  side  of  the  frenum,  release  the  suture  from  the 


Fig.  29— Cutting  Off  Prepuce. 

Note  :  Two  gentlemen  assisted  at  the  operation  above  depicted.  When  performed  with  one 
assistant  the  upper  end  of  the  frenal  suture  can  be  held  by  the  ring  and  little  fingers  of  the  hand 
that  holds  the  clamp. 

clamp  lying  on  the  scrotum  and  give  its  ends  to  the  assistant, 
who  stretches  them  apart  while  placing  the  penis  on  the  pubis. 

25.  Take  the  gauze  strip  pendent  from  the  left  side  and  lay 
it  smoothly  to  the  right  side  of  the  penis,  upon  the  knot  of  the 
suture  being  stretched  by  the  assistant.  Then  place  the  end  of 
gauze  pendent  from  the  right  side  and  cross  it  to  the  left  (Fig. 
31) .     Firmly  tie  the  two  ends  of  gauze  within  the  last  suture. 

26.  Cut  off  the  projecting  ends  of  gauze  and  trim  the  catgut 
sutures  beyond  their  knots,  leaving, a  smooth  neat  collar  of 
gauze,  about  a  quarter  of  an  inch  behind  the  corona,  firm  enough 
to  press  any  ununited  parts  of  the  wound  into  coaptation,  but 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.  99 


Fig.  30.— Applying  Gauze  Collar. 


not  tight  enough  to  exert  the  slightest  pressure  upon  the  penis 
or  give  pain  during  erection  (Fig.  32). 

A  little  blood  will  ooze  into  the  collar.      This  will  swell 


Fig.  31.— Closing  Gauze  Collar. 


100 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


slightly,  and  in  so  doing  press  any  little  gapings  of  tlie  wound 
lips  together. 

A  light  gauze  bandage  will  steady  the  ring  in  walking.  It 
should  be  so  applied  as  to  leave  the  whole  glans  free,  that  none 
of  the  dressing  be  soiled  by  urination.  As  the  glans,  so  ex- 
posed, would  suffer  from  friction  with  the  clothing,  it  must  be 
covered  thickly  with  vaseline,  over  which  a  wad  of  absorbent  cot- 
ton is  placed  and  tied  around  the  penis  with  a  strip  of  gauze. 


Fig.  33.— Circumcision  Completed. 


After  each  urination,  fresh  vaseline  and  cotton  are  applied  by 
the  patient.  In  two  or  three  days  the  mucosa  over  the  glans 
will  be  sufficiently  hardened  to  render  this  protection  unneces- 
sary. 

If  the  patient  requires  treatment  for  gonorrhoea,  irrigations 
can  be  performed,  and  by  using  a  little  additional  care  in  hand- 
ling the  penis,  without  pain  from  the  operation. 

Ordinarily,  i.e.  when  the  patient  requires  no  treatment  for 
gonorrhoea  that  moistens  this  dressing,  the  gauze  ring  will  in  a 
day  become  as  hard  as  stiff  pasteboard.  In  from  four  to  eight 
days  the  catgut  holding  the  wound  lips  together  will  be  ab- 
sorbed; the  ring  will  then  drop  off,  leaving  the  line  of  primary 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.        101 

■union  in  evidence  of  tlie  care  and  neatness  with  wliicli  tlie 
operation  lias  been  performed. 

In  circumcising  children  or  unruly  boys,  general  ansesthesia 
proves  preferable  to  infiltration.  When  the  latter  is  properly 
employed,  it  renders  the  entire  operation  absolutely  painless. 

When  phimosis  accompanies  gonorrhoea,  associated  with 
chancre  or  chancroid,  the  danger  of  sloughing  of  the  wound 
prohibits  circumcision.  As,  however,  the  clap  must  be  treated 
and  as  the  sores  may  produce  large  destruction  of  tissue,  unless 
they  receive  attention,  it  becomes  necessary  to  expose  the  glans 
entirely.  This  is  best  accomplished  by  two  lateral  incisions, 
one  on  each  side  of  the  penis,  half-way  between  the  frenum  and 
the  dorsal  median  line  of  the  foreskin.  In  most  cases,  Taylor's 
phimosis  scissors  will  be  found  useful;  still  as  often  very  hard 
preputial  infiltrations  may  render  its  employment  difficult,  a 
stout,  slightly  curved  sharp-point  bistoury  will  be  found  more 
effective.  It  is  passed  upon  a  grooved  director  which  has  been 
inserted  into  the  coronary  sulcus,  the  preputial  skin  drawn  back 
as  far  as  possible,  the  knife  made  to  penetrate  the  mucosa,  the 
intervening  tissue  and  to  project  from  the  skin,  cuts  a  steady, 
straight  line  outward.     This  cut  is  repeated  on  the  opposite  side. 

The  operation  should  be  preceded  by  very  thorough  anti- 
septic irrigation  of  the  preputial  sac.  After  both  sides  of  the 
prepuce  are  slit,  a  large  flap  of  foreskin  projecting  above  and 
another  hanging  below  will  expose  the  entire  glans  for  examina- 
tion and  treatment  as  soon  as  bleeding  has  ceased. 

Pollutions. — There  is  no  symptom  in  connection  with  gon- 
orrhoea that  does  less  harm  and  creates  more  consternation  than 
an  emission  of  semen,  especially  in  a  patient  whose  mind  has 
been  misdirected  by  quack  advertisements.  It  is  often  difficult 
to  persuade  such  a  patient  into  appreciation  of  the  essential 
facts,  viz. : 

1.  That  in  abstinence  from  sexual  intercourse  occasional 
emissions  of  semen  from  the  overfilled  seminal  vesicles  are  i)er- 
fectly  normal. 

2.  That  the  local  irritation  of  gonorrhoea  is  likely  to  evoke 
emissions  more  frequently  than  they  would  occur  in  health. 

3.  That  no  proximate  or  remote  injury  will  come  to  the  pa- 
tient from  such  emissions,  when  they  are  not  too  frequent.  Their 
frequency  may  vary  widely  within  normal  limits. 


102  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

4.  That  only  wlien  tlie  semen  emitted  is  bloodj^  or  wlien  its 
emission  gives  pain  enougli  to  awake  the  patient,  is  it  indica- 
tive of  seminal  vesiculitis  and  then  requires  attention. 

If  the  patient's  intellect  is  too  limited  to  permit  him  to  grasp 
these  ideas,  the  physician  is  perfectly  justified  in  employing 
such  subterfuges  as  will  best  appeal  to  the  patient's  understand- 
ing. The  one  that  succeeds  most  frequently  is  to  felicitate  the 
patient  on  the  occurrence  of  these  pollutions  and  to  offer  him 
remedies  that  will  cause  their  continuance.  The  "remedies" 
then  prescribed  must  naturally  be  only  placebos. 

At  the  same  time,  a  towel  tied  around  the  waist  and  heavily 
knotted  over  the  spine  to  prevent  the  patient  sleeping  on  his 
back,  and  light  evening  meals,  will  contribute  to  reducing  the 
frequencj^  of  pollutions. 

Prostatitis. — Wossidlo'  insists  that  no  case  of  gonorrhoea 
be  dismissed  as  cured  before  the  physician  has  assured  himself 
that  the  prostate  is  free  from  invasion.  If  this  advice  were  al- 
ways followed,  there  would  be  few,  if  any,  cases  of  recurrent 
gonorrhoea. 

The  almost  direct  manner  in  which  the  prostatic  ducts  empty 
into  the  posterior  urethra  seems  to  invite  infection  from  this 
region  to  the  prostate,  by  continuity  of  surface.  Bransford 
Lewis^  supports  his  own  studies  of  the  frequency  of  infection  of 
the  posterior  urethra,  by  the  statistics  of  other  authors,  such  as 
Letzel,  who  found  posterior  urethritis  in  92.5  per  cent,  of  gon- 
orrhoeas, Jadassohn  in  87.7  per  cent.,  Eona  in  79.7  per  cent. 
My  own  observations  have  led  to  the  views  expressed  in  the 
chapter  on  Acute  Posterior  Gonorrhoea. 

Like  posterior  urethritis,  gonorrhoeal  prostatitis  may  give 
but  slight  or  practically  no  manifestations  of  its  presence.  It 
is  therefore  likely  to  be  overlooked  unless  one  makes  it  a  rule 
to  follow  Wossidlo's  sage  advice. 

A  slight  discomfort  about  the  perineum  and  rectum  may  be 
the  only  indication  of  the  disease.  If  this  does  not  receive  at- 
tention, pain  referred  more  directly  to  the  bladder  may  follow. 

^Wossidlo;  "Treatment  of  Chronic  Prostatitis."  Journal  of  the  Ameri- 
can Medical  Association,  August  27th,  1898. 

,,  2 Lewis:  "The  R61e  of  the  Posterior  Urethra  in  Chronic  Urethritis." 
Read  before  the  American  Association  of  Genito-Urinary  Surgeons,  June  21st, 
1893  (reprint  from  Medical  Record). 


COMPLICATIONS   AND    SEQUELS    OF   GONORRHCEA.        103 

The  pain  is  accentuated  by  urination  and  defecation,  especially 
when  efforts  are  necessary  to  expel  hard  fseces.  The  patient  is 
obliged  to  urinate  frequently,  but  does  not  experience  complete 
relief  from  the  act.  While  the  frequency  may,  in  great  degree, 
be  caused  by  the  coincident  posterior  urethritis,  there  is  neces- 
sarily an  amount  of  urine  retained  in  the  bladder.  The  quantity 
of  residual  urine  is  in  proportion  to  the  degree  of  prostatic 
engorgement.  This  pushes  that  part  of  the  bladder  which  lies 
over  the  prostate  upward  into  the  vesical  cavity.  Behind  this 
elevation  a  trough  is  produced,  from  which  the  bladder  con- 
tractions do  not  suffice  to  force  all  the  urine  it  contains  above 
the  hillock  made  by  the  enlargement.  Sometimes  the  entire 
lower  part  of  the  enlarged  prostate  juts  into  the  bladder  cavity 
in  such  a  manner  as  to  form  a  species  of  valve.  This  is  shown 
after  such  a  patient  has  voided  all  the  urine  he  can  extrude  by 
irrigating  his  bladder  with  a  potassium  permanganate  solution. 
No  difficulty  opposes  the  inflowing  solution,  because  it  forces 
the  prostate  back  toward  its  place.  But  when  the  patignt  voids 
all  he  can  of  the  solution,  it  will  be  found  decolorized  by  the 
retained  urine  if  it  is  normal,  or  rendered  brown,  "muddy,"  in 
case  the  urine  has  become  septic. 

The  prostate  in  this  condition  may  cause  "  stammering  " 
urination,  as  Guyon  graphically  describes  it.  The  patient,  by  a 
series  of  contortions,  invites  the  stream  which,  while  he  holds 
himself  in  a  certain  position,  may  flow  freely;  then  suddenly 
an  untoward  motion  throws  the  enlarged  prostate  against  the 
internal  meatus  and  urination  stops.  The  greater  the  efforts 
made,  the  more  firmly  is  the  bladder  outlet  blocked.  Only  after 
successful  efforts  at  relaxation  does  the  prostate  fall  back  and 
allow  the  urine  to  flow.  But  the  bladder  contractions  may  force 
the  prostate  up,  and  let  it  drop  again,  producing  the  character- 
istic stammering.  The  end  of  urination  may  be  painful  and 
accompanied  by  emission  of  pus  and  blood.  When  the  conclu- 
sion of  urination  is  so  disturbed,  neither  the  pain  nor  extrusion 
of  pus  and  blood  is  as  marked  as  in  acute  posterior  urethritis. 
Naturally,  if  the  prostatic  trouble  accompanies  posterior  ure- 
thritis in  the  fulminant  form,  the  severe  symptoms  of  the  latter 
will  overshadow  those  produced  by  the  engorged  prostate. 

The  frequency  with  which  acute  prostatitis  complicates  pos- 
terior urethritis  is  disputed.     This  may  be  due  to  the  omission 


104 


THE   IRRIGATION  TREATMENT   OF   GONORRHCEA. 


of  prostatic  examination  and  to  subsidence  of  its  severer  symp- 
toms with  tlie  decrease  of  those  of  the  urethritis. 

On  examining  the  prostate  per  rectum,  the  finger  finds  the 
gut  hot,  more  or  less  firm  and  tender  to  the  touch,  according  to 
the  degree  of  inflammation.  The  anterior  wall  itself  bulges 
downward  and  backward  into  the  rectal  space.  The  enlarged 
prostate,  very  tender  to  the  touch,  can  be  outlined  through  the 
rectal  wall.  These  findings  are  the  only  ones  by  which  prosta- 
titis can  be  differentiated  from  posterior  urethritis. 

The  rational  division  of  this  complication  into  simple  acute 
prostatitis,  acute  follicular  and  parsnchymatous  prostatitis  is 
sufficiently  explanatory  of  the  varieties.     Their  detailed  con- 


f^ 


Fig.  33.— White  and  Martin's  Rectal  Injector. 


sideration  is  unnecessary  in  a  book  limited  to  treatment,  which 
does  not  materially  differ  in  the  several  forms  of  the  disease. 

If  the  case  is  seen  at  the  inception  of  the  prostatic  involve- 
ment, the  patient  must  be  put  to  bed,  with  a  sewing-board  or 
leaf  of  an  extension  table  under  that  part  of  the  mattress  upon 
which  his  buttocks  rest.  Upon  this  a  thick  hair  pillow  is  placed 
to  elevate  the  pelvis.  The  intestinal  discharges  are  kept  soft 
by  skimmed  milk  to  the  exclusion  of  other  food,  and  the  urine 
bland  by  alkaline  diuretics.  Irrigations  of  the  urethra  and 
bladder  are  as  a  rule  exceedingly  well  borne  during  acute  prosta- 
titis, especially  when  the  manifestations  of  posterior  urethritis 
are  marked. 

If  perineal  pain  and  vesical  tenesmus  are  severe,  leeches  to 
the  xjerineum  will  furnish  relief. 

Eectal  irrigations,  hot  or  cold,  according  to  the  local  and 
general  condition,  often  give  very  prompt  relief.  The  most  con- 
venient instrument  for  these  irrigations  is  the  rectal  injector 


COMPLICATIONS   AND   SEQUELS    OF   GOXORRHCEA.        105 

described  by  White  and  Martin,  wlio  direct  its  use  as  follows : 
"  A  quart  of  a  seven-tenths-per-cent.  salt  solution  is  heated  from 
110°  to  115°  r.,  and  the  injection  pipe  is  introduced  into  the 
anus  and  its  end  tilted  upward  and  forward  so  that  the  stream 
when  it  is  turned  on  shall  flow  directly  on  the  prostatic  tumor 
as  it  bulges  into  the  rectum.  The  exit  pipe  allows  the  fluid  to 
flow  away  as  fast  as  it  enters  the  bowel.  This  treatment  should 
be  repeated  two  or  three  times  a  day." 

When  using  this  rectal  irrigator,  I  found  that  larger  quanti- 
ties of  hot  water,  two  or  even  three  quarts,  gave  more  relief  than 
one.     After  each  rectal  irrigation  a  suppository  of 

Iodoform,  pulv.,     .         .         .         .         .         .         •  gr.  ss.-iss. 

Codein.  phosph., gr.  |— i. 

01.  theobrom., q.  s.   " 

will  aid  in  resolution,  and  further  assuage  pain. 

Some  patients  bear  cold  irrigations  much  better  than  hot 
ones.  In  the  beginning  of  jjrostatic  involvement  they  occasion- 
ally act  better;  indeed,  if  used  early  enough,  they  often  appear 
to  abort  the  case. 

Hot  baths,  and  particularly  hot  sitz-baths,  twice  or  three 
times  daily,  of  ten  to  twenty  minutes'  duration  each,  will  often 
give  marked  relief.  Li  some  cases  a  hot-water  bag  to  the  peri- 
neum aids  in  making  the  patient's  condition  tolerable. 

Persistent  severe  pain  and  tenesmus,  both  vesical  and  rectal, 
may  oblige  recourse  to  opium  administered  by  the  rectum  or 
morphine  injected  deeply  into  the  perineum. 

When  prostatic  enlargement  prevents  urination  and  the  oth- 
er means  suggested  for  relief  fail,  or  when  the  emergency  of 
the  case  demands,  recourse  must  be  had  to  catheterization.  As 
repetition  of  the  use  of  the  catheter  will  be  required,  and  is 
painful,  it  will  be  well,  when  the  urine  is  retained  because  of 
prostatitis,  to  employ  permanent  catheterization  (see  Ketention). 

If  the  prostate  has  become  the  site  of  pus  formation,  no 
time  should  be  lost  by  any  of  the  above  procedures.  Palpation 
through  the  rectum  will  reveal  whether  fluctuation  points  toward 
the  bowel.  If  it  does  not,  fairly  moderate  pressure  may  cause 
the  pus  to  escape  into  the  urethra;  indeed,  it  is  often  so  re- 
lieved by  nature.  In  case  this  effort  fail,  it  may  be  supple- 
mented by  the  introduction  of  a  Benique  or  Guy  on  sound,  which 


106 


THE   IRRIGATION   TREATMENT    OF   GONORRHOEA. 


offers  increased  resistance,  and  performing  massage  while  the 
sound  is  held  in  the  bladder.  But  unless  the  physician  has 
large  experience  in  the  use  of  genito-urinary  instruments  and  is 

endowed  with  great  delicacy  of  touch 
he  should  certainly  avoid  the  use    of 
these    sounds,   es- 
pecially   in    acute 
inflammatory  con- 
ditions. 

I  f  fluctuation 
does  not  distinctly 
point  rectumward, 
and  if  nature  or 
massage  does  not 
empty  the  pus  into 
the  urethra,  a  me- 
d.i  a  n  perineal 
incision  will  be  re- 
quired for  its  evac- 
uation and  sub- 
sequent thorough 
drainage. 

When,  how- 
ever, pus  distinctly 
points  to  the  rec- 
tum, it  may  b  e 
considered  as  na- 
ture's indication  of 
the  most  favorable 
site  for  evacuation. 
Acting  upon  this 
suggestion,  I  have, 
i  n  eight  cases, 
opened  prostatic 
abscess  by  a  long 
incision  through 
the  anterior  rectal  wall,  packed  the  cavity  with  iodoform  gauze, 
and  have  not  observed  one  case  of  general  infection.  It  is  true 
that  in  each  of  these  cases  the  rectum  was  on  the  point  of  break- 
ing down  when  I  operated. 


COMPLICATIONS   AND    SEQUELAE    OF   GONORRHCEA.        lOT 

In  tlie  above,  termination  of  prostatitis  by  resolution  or  sup- 
puration only  lias  been  considered.  Prostatitis  may  also  go 
over  into  a  clironic  inflammation  of  the  gland.  Chronic  prosta- 
titis may  also  be  a  sequel  to  clironic  posterior  urethritis  or 
cystitis,  with  no  appreciable  acute  prostatitis  preceding  it.  The 
gland  being  predisposed  by  congestion,  it  is  easily  susceptible 
to  infection.  Any  disturbance  producing  pelvic  engorgement, 
irritating  injections,  continued  sexual  excesses,  masturbation, 
hemorrhoids,  concentrated  urine,  habitual  constipation,  may 
produce  congestion  of  the  prostate. 

The  symptoms  of  chronic  prostatitis  differ  but  little  from 
those  of  chronic  posterior  urethritis.  The  most  marked  dif- 
ference is  in  a  burning  pain  distinctly  referred  to  a  point  almost 
immediately  behind  the  fossa  navicularis.  Urination  may  be 
followed  by  and  defecation  associated  with  an  emission  of  a  milk- 
like fluid,  which  on  examination  is  found  to  consist  of  prostatic 
juice,  amyloid  prostatic  bodies,  occasionally  blood,  epithelium 
from  the  prostate  and  its  ducts,  and  i)us.  The  pain  after  urina- 
tion and  defecation  or  either  may  be  severe,  lasting  sometimes 
for  several  hours.  It  may  radiate  from  deep  in  the  perineum  to 
the  rectum,  testicles,  and  down  the  thighs,  and  is  aggravated  by 
motion  or  effort  of  any  kind. 

The  perineum  is  tender  to  touch.  Kectal  examination  of  the 
prostate  shows  it  to  be  irregularly  nodulated  or  asymmetric. 
After  massage,  the  urine  contains  considerable  pus. 

The  mind  and  nervous  system  suffer  perhaps  more  in  chronic 
prostatitis  than  in  any  other  genito-urinary  affection  excepting 
seminal  vesiculitis.  These  sufferings  are  aggravated  when  ac- 
companied by  reduction  or  loss  of  sexual  desire.  The  patient 
then  becomes  markedly  neurasthenic  and  even  melancholic, 
with  the  usual  accompaniment  of  general  depressed  physical 
tone. 

The  constitutional  treatment  of  such  cases  demands  regular- 
ity in  meals,  consisting  of  nutritious,  bland,  easily  digestible 
food;  systematic  exercise,  preferably  walking  in  the  open  air, 
not,  however,  to  the  extent  of  tiring  the  patient,  and  a  sufficiency 
of  sleep. 

Locally,  rectal  injections  of  a  pint  of  hot  water  retained  as 
long  as  possible  and  followed  by  a  suppository  of  iodoform  and 
codeine  phosphate,  twice  or  three  times  daily,  will  afford  relief. 


108  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Hot  sitz-baths  twice  or  tliree  times  daily  will  also  aid  in  tlie 
treatment. 

Massage  of  the  prostate  every  second  day  will  empty  the 
organ  of  pus  that  has  accumulated,  and  will  relieve  congestion 
if  it  contains  no  pus.  The  most  beneficial  manner  of  securing 
this  end  is  by  a  complete  intravesical  irrigation  with  boric  acid, 
four  per  cent.,  followed  by  filling  the  bladder  with  the  same 
solution,  after  its  first  washing  has  been  passed  out.  The 
massage  is  performed  after  the  bladder  has  been  almost  filled 
for  the  second  time.  The  fluid  then  passed  will  be  found  turbid 
with  the  substances  expressed  from  the  prostate.  If  the  patient 
can  stand  a  third  intravesical  irrigation,  one  of  silver  nitrate 
1:5,000  or  1:3,000,  according  to  his  vesical  tolerance,  may  be 
advantageously  used  (see  also  Kectal  Palpation  of  the  Urethral 
Adnexa). 

Patients  with  chronic  prostatitis  are  liable  to  acute  intercur- 
rences.  These  must  be  treated  as  suggested  for  acute  prosta- 
titis. 

Betention  of  ueine  is  rare  in  gonorrhoea.  It  may  occur  in 
very  hyperacute  cases,  or  in  those  aggravated  by  alcohol,  coi- 
tus, masturbation,  irritating  injections,  or  the  introduction  of  in- 
struments. Invasion  of  the  prostate  and  the  presence  of  even 
large  calibre  strictures  may  produce  retention  of  urine  in  gonor- 
rhoea, by  the  urethrospasm  they  are  likely  to  provoke. 

When  a  patient  with  gonorrhoea  cannot  pass  urine,  he  is 
usually  in  such  agony  that  the  history  of  the  case  cannot  be  ob- 
tained. It  will  be  well,  before  attempting  to  unload  the  blad- 
der, to  examine  the  prostate.  If  the  finger  inserted  into  the 
rectum  feels  the  prostate  to  be  enlarged,  hot  and  sensitive  to 
touch,  the  retention  is  attributable  to  at  least  congestion  of  this 
gland.  If  the  prostate  be  found  normal,  any  or  several  of  the 
above  causes  may  be  at  the  bottom  of  the  retention. 

The  patient  should  be  at  once  placed  in  a  hot  bath,  hot 
enemata  given  him,  followed  by  a  suppository  of  iodoform  and 
opium.  If  these  fail  to  relieve  the  emergency,  the  following 
steps  for  evacuating  the  bladder  may  be  employed : 

1.  Irrigate  the  anterior  urethra  with  potassium  permanganate 
1:6,000  or  boric  acid  four  per  cent.  The  solution  should  be 
at  a  temperature  of  between  110°  and  120°  F.  This  irrigation 
alone  often  suffices  to  relieve  the  spasm. 


COMPLICATIONS   AND   SEQUELS   OP   GONORRHCEA.        109 

2.  After  using  750  c.c.  (one  and  a  lialf  pints)  of  eitlier  of  tlie 
above  solutions,  inject  one  or  two  draclims  of  a  warm  two-per- 
cent, solution  of  eucaine  into  tlie  urethra.  Hold  it  there  by  com- 
pressing the  sides  of  the  glans  with  the  left  thumb  and  index 
finger.  Stroke  the  urethra  with  the  right  fingers  at  first  gently, 
then  with  increasing  pressure,  to  force  the  eucaine  solution 
beyond  the  site  of  the  spasm,  which  is  usually  located  in  the 
membranous  portion. 

3.  Kemove  the  nozzle  from  the  irrigator  tube  and  attach  in 
its  place  a  sterilized  semi-soft  French  conical,  well-lubricated 
catheter. 

4.  Insert  the  catheter,  and  when  its  eye  is  beyond  the  meatus 
let  the  irrigating  fluid  pass  through  it. 

5.  Very  gently  glide  the  catheter  onward,  striving  to  reach 
the  bladder  before  the  entire  contents  of  the  irrigator  have 
escaped  from  the  urethra.  If  the  catheter  in  its  onward  course 
meets  an  obstacle  which  it  cannot  overcome  without  force, 
withdraw  the  instrument  an  eighth  or  a  quarter  of  an  inch  and 
endeavor  to  insert  it  in  slightly  different  directions  until  the 
lumen  is  found. 

6.  If  the  semi-soft  catheter  fails  to  enter  the  bladder,  re- 
course must  be  had  to  a  silver  catheter,  employing  all  the  pre- 
cautions mentioned  above. 

7.  When  the  catheter  has  reached  the  bladder,  detach  the 
irrigator  tube  and  allow  about  90  c.c.  (three  ounces)  of  urine  to 
escape  slowly  by  checking  the  stream  with  the  finger  over  the 
mouth  of  the  catheter.  When  this  amount  has  flowed  off,  inject 
60  c.c.  (two  ounces)  of  four-per-cent.  warm  boric-acid  solution. 
Again  allow  90  c.c.  to  escape  slowly  from  the  bladder,  and  repeat 
the  injection  of  60  c.c.  boric  acid.  Eesume  these  alternate  slow, 
small  emissions  and  injections  until  the  fluid  that  flows  from 
the  catheter  proves  to  be  clear  boric-acid  solution.  Then  in- 
ject 60  c.c.  of  boric-acid  solution  and  withdraw  the  catheter  until 
its  eye  is  just  beyond  the  compressor.  This  will  be  manifest 
by  cessation  of  flow  from  its  mouth. 

8.  Ee-attach  the  irrigator  nozzle  and  allow  250  c.c.  (one-half 
pint)  of  warm  boric-acid  solution  to  run  through  the  catheter 
while  it  is  being  removed  from  the  urethra. 

9.  Urge  the  patient  to  retain  the  boric  acid  left  in  his  blad- 
der for  at  least  an  hour. 


110  THE   IREIGATION   TREATMENT    OF   GONORRHCEA. 

10.  If  three  hours  later  the  patient  cannot  empty  his  blad- 
der without  assistance,  catheterize  again  as  above  directed. 
The  main  purpose  of  the  slowness  advocated  is  threefold : 

(a)  The  continuous  flow  of  the  warm  solution  through  the 
catheter,  while  it  is  being  passed  through  the  urethra,  is  in- 
tended, as  far  as  possible,  to  prevent  carrying  infection  to  the 
bladder.  At  the  same  time  "its  temperature  may  aid  in  over- 
coming the  urethral  tumefaction  and  such  spasm  as  may  exist. 

(b)  Slowly  emptying  the  bladder  gives  it  better  opportunity 
to  regain  its  muscular  tone,  which  may  be  seriously  impaired  by 
overdistention. 

(c)  Kapidly  emptying  the  bladder  to  relieve  retention  may  be 
followed  by  dangerous  hemorrhage  ex  vacuo. 

In  some  very  rare  cases,  great  difficulty  may  be  experienced 
in  inserting  a  catheter,  when  a  second  emptying  of  the  bladder 
becomes  necessary.  The  question  of  permanent  catheterism 
then  arises.  It  naturally  involves  the  risk  of  impeding  the 
free  escape  of  pus  from  the  urethra  and  of  infecting  the  bladder. 
Equally  its  omission  may  allow  the  congestion  of  the  urethra 
or  of  the  prostate  or  both  to  increase,  effectually  shutting  off  the 
outflow  of  urine,  with  all  its  dangers. 

In  such  a  rare  case  it  is  advisable  to  provide  continuous 
bladder  drainage,  with  a  catheter  too  small  to  block  the  urethral 
discharge.  The  presence  of  the  catheter  in  the  urethra  and 
bladder  will  serve  to  reduce  the  thickening  of  the  urethra  and 
of  the  prostate,  if  both  are  congested,  as  is  shown  by  the  free 
voluntary  outflow  of  urine  alongside  the  catheter  in  a  very  few 
hours.  Repetition  of  catheterization  will  then  not  become  neces- 
sary. 

The  easiest  and  safest  method  of  fastening  the  catheter  in  the 
bladder  is  the  one  we  owe  to  Guy  on,  ^  whose  directions  are  con- 
densed as  follows : 

1.  Cut  two  pieces  of  firm  knitting  yarn  each  one  metre 
(about  forty  inches)  long. 

2.  Fold  them  in  half,  and  tie  the  free  ends  of  each  separately. 

3.  Place  the  strings  in  bichloride  or  boric-acid  solution. 

4.  Insert  the  catheter  and  so  i^lace  it  that  the  urine  comes 


'  Guyon :   LeQons  cliniques  sur  les  Maladies  des  Voies  Urinaires,  vol.  iii., 
Bailli^re,  Paris,  1897. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.        Ill 


from  its  mouth  in  single  drops.  Watcli  this  dropping  for  sev- 
eral minutes;  if  the  urine  is  occasionally  emitted  in  a  little 
stream,  or  if  it  stops  entirely,  move  the  catheter  either  a  trifle 
more  deeply  into  the  bladder  or  an  equal  distance  forward  until 
permanent  dropping  of  urine  is  secured. 

5.  Take  one  of  the  doubled  strings  from  the  antiseptic  solution, 
fold  it  in  half  again,  and  tie  it  firmly  around  the  catheter,  exactly 
at  the  level  of  the  meatus  (A)  (Fig.  36).  Then  take  its  two  double 
ends  to  the  side  of  the  penis,  hold  them  together  at  the  coronary 
sulcus  (B')  and  tie  another 
knot  there.  Keep  this  knot 
at  the  sulcus  (B)  exactly 
half-way  between  the  f renum 
and  the  dorsum  of  the  penis. 
Separate  the  doubled  strings 
and  pass  them  around  the 
penis,  to  be  tied  in  a  firm 
knot  at  the  corresponding 
side  (B').  The  double 
string  collar  thus  tied  about 
the  neck  of  the  penis  must 
not  be  tight  enough  to  cause 
even  inconvenience  should 
an  erection  occur. 

6.  Tie  the  second  doub- 
led string  (which  appears 
as  dotted  line  in  Fig.  36)  in 
the  same  manner  as  the  first 
doubled  string  was  attached 

to  the  catheter.  Place  the  first  knot  in  the  second  doubled 
string  immediately  in  front  of  the  first  string  and  directly  op- 
posite the  first  knot.  Carry  both  ends  of  the  second  string 
to  the  knot  that  completed  the  coUar  (B').  Tie  a  knot  in  the 
second  string  there.  Separate  the  cords  that  form  the  first 
string  as  it  makes  the  collar  at  each  side  of  the  knot  and  pass 
each  end  of  the  second  string  through  the  separations.  Tie 
them  in  a  knot  upon  the  first  string's  knot  (B').  Pass  the  two 
ends  of  the  second  string  around  the  neck  of  the  penis  as  those 
of  the  first  string  were  passed,  but  in  the  opposite  direction, 
forming  another  collar.     Close  the  collar  by  a  knot  at  B  and 


Fig.  36.— Fastening  Catheter  into  Bladder. 
(Guyon  :  "  Voies  Urinaires.") 


112  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

fasten  tlie  strings  there  in  the  same  manner  as  they  were  fast- 
ened at  B'. 

7.  Take  up  a  bunch  of  hair  at  about  an  inch  from  the  root 
of  the  penis  (C)  and  twist  it  into  the  shape  of  a  moustache. 
Lay  the  string  alongside  of  the  penis  like  a  rein,  and  where  it 
touches  the  moustache,  without  stretching  or  moving  the  penis 
from  the  exact  median  line ;  tie  it  firmly  about  the  root  of  the 
moustache.  As  this  knot  will  envelop  the  base  of  a  pyramid 
of  hair,  it  will  be  likely  to  slip  off ;  therefore  double  the  mous- 
tache upon  itself  and  with  another  knot  fix  the  rein  in  place. 


Fig.  37. — Drainage  into  Urinal. 
(Guyon :  "  Voies  Urinaii'es.") 

Eepeat  this  procedure  with  the  other  rein  that  hangs  from  the 
collar  at  B',  attaching  it  to  C,  opposite  the  first  moustache. 

After  so  fastening  the  catheter  in  place,  the  condition  of  the 
bladder  must  decide  whether  continued  drainage  or  interrupted 
evacuation  should  be  employed.  In  a  general  way  it  may  be 
laid  down  that  if  the  bladder  is  infected,  continued  drainage  with 
continual  washing  will  be  necessary ;  if  the  bladder  is  not  in- 
fected, interrupted  evacuation  is  easily  obtained  by  plugging  the 
month  of  the  catheter  with  a  wooden  spigot.  This  spigot  can 
be  removed  each  time  it  becomes  necessary  to  empty  the  bladder. 

Continuous  drainage  of  the  bladder  is  best  accomplished  by 
attaching  a  rubber  tube  eight  inches  long  to  the  mouth  of  the 
catheter,  and  inserting  it  into  the  bottom  of  the  tube  (D)  of  a 
Duchastelet  antiseptic  urinal,  containing  a  solution  of  bichloride 
1 : 1,000.  A  similar  quantity  of  the  same  solution  may  be  poured 
into  the  bowl  of  the  urinal,  through  its  opening  C,  after  the 
urinal  is  placed  between  the  patient's  thighs.  The  purpose  of 
placing  the  urinal  between  the  patient  thighs  is  to  protect  the 


COMPLICATIONS   AXD   SEQUELS    OF   GONORRHCEA.        113 

bed,  to  alloTV  tlie  patient  some  latitude  in  motion  and  to  pre- 
vent the  bending  of  tlie  penis  and  the  catheter  it  contains,  thus 
insuring  its  continuous  free  action. 

Whether  it  is  determined  to  employ  continuous  or  inter- 
rupted vesical  evacuation,  the  penis  should  be  "  dressed  "  in  the 
manner  laid  down  by  Guy  on.  This  dressing  is  made  with  three 
pieces  of  salicylated  or  carbolated  gauze  25  cm.  (about  ten  inches) 
square.  These  are  folded  in  half,  from  one  angle  to  its  opposite 
one,  making  a  triangle  of  six  layers  of  gauze.  The  base  of  this 
triangle  is  passed  close  to  the  penoscrotal  angle,  and  the  two 
angles  at  the  base  are  doubled  over  the  penis  so  that  the  one 
projecting  to  the  right  of  the  penis  reaches  the  left  side  of  the 
pubis,  where  the  strings  holding  the  catheter  are  tied  to  the 
hairs  (see  Fig.  37).  It  is  firmly  attached  to  this  spot  with 
the  string  that  was  left  hanging  there.  The  angle  of  the  gauze 
triangle  projecting  from  the  left  side  of  the  penis  is  folded  over 
to  the  right  tied  moustache  and  attached  firmly  to  it.  The 
moustache  strings  are  then  cut  off.  The  penis  is  thus  com- 
pletely enveloped  by  the  gauze.  To  prevent  its  slipping  up- 
ward, the  .angle  around  the  catheter  is  tied  to  it  by  another 
piece  of  string. 

While  it  is  undoubtedly  a  grave  violation  of  surgical  prin- 
ciples to  insert  any  instrument  into  an  acuteh'  inflamed  urethra, 
I  must  confess  that  I  was  driven  to  it  in  three  cases.  In  each 
of  these  the  urethra  was  lacerated  from  attempts  to  pass  cath- 
eters for  the  relief  of  retention.  No  aspirator  or  trocar  was 
within  several  hours'  reach,  and  the  patients  were  in  acute  suf- 
fering, with  high  fever.  I  was  fortunate  enough  to  get  cathe- 
ters into  these  bladders.  One  remained  four  hours,  another  six 
hours,  and  the  third  eighteen  hours.  Naturally  all  possible 
antiseptic  precautions  were  taken.  In  none  of  the  three  cases 
did  vesical  infection  result,  nor  was  the  gonorrhoea  materially 
aggravated  from  the  use  of  the  catheter. 

Should  it  be  impossible  to  pass  a  catheter,  after  the  prelimi- 
nary- efforts  (hot  baths,  etc.)  have  failed,  it  will  be  necessary  to 
either  aspirate  or  evacuate  part  of  the  bladder  contents  hj  a 
trocar  through  the  suprapubic  space.  In  many  cases  it  will  be 
found  that  after  removal  of  perhaps  one-fifth  of  the  retained 
urine,  the  patient  will  be  able  to  empty  the  remainder  through 
the  urethra,  owing  to  relief  from  the  tension. 


114  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

If  prostatic  congestion  causes  the  retention,  catiieters  of  tlie 
Mercier  curve  will  be  found  most  useful.  Guy  on  suggested 
various  lengths  of  beaks  and  angles  at  which  the  beaks  are  at- 
tached to  the  shafts  for  easier  introduction  and  more  comfort- 
able retention,  according  to  the  degree  of  prostatic  swelling. 
Those  most  frequently  used  are  shown  in  Fig.  38.  Their  press- 
ure upon  the  prostate  proves  valuable,  while  placing  the  reten- 
tion of  urine  under  control.     When,  however,  evidence  of  pus 


Fig.  38.— Guyon  Beaks  of  Mercier  Catheters. 

formation  in  the  prostate  presents,  the  abscess  cavity  must  be 
promptly  emptied. 

Eheumatism  (gonorrhoeal).— a  somewhat  extensive  study  of 
the  literature  of  gonorrhoea  makes  Bransford  Lewis  appear  the 
first,  at  least  among  American  writers,  to  show  that  infection  of 
the  posterior  urethra  is  far  more  frequent  than  is  ordinarily 
assumed.  This  author,'  in  an  interesting  and  instructive  mono- 
graph, shows  that  posterior  urethritis  is  almost  invariably  pres- 
ent in  every  case  of  prolonged  or  severe  gonorrhoea.  He  further 
asserts  that  the  gonococci,  instead  of  gradually  progressing  along 


•Lewis:  "The  Role  of  Posterior  Urethra  in  Chronic  Urethritis."  Read 
before  the  American  Association  of  Genito-Urinary  Surgeons,  June  21st,  1893, 
Medical  Record. 


COMPLICATIONS   AND    SEQUELS    OF   GONORRHCEA.        115 

tlie  urethral  mucosa  to  penetrate  eventually  the  compressor  in 
two  or  more  weeks  after  the  onset  of  the  disease,  are  promptly 
carried  back  through  the  lymphatics.  About  the  same  time 
Kona,  of  Budapest,  made  similar  assertions,  but  his  thoughts 
on  the  subject  were  presented  more  tentatively  than  were  the 
findings  of  Lewis. 

The  facts  exposed  by  these  authors  emphasize  the  need  of 
intravesical  irrigations  (see  page  29)  even  when  gonorrhoea 
seems  to  affect  only  the  anterior  urethra.  At  all  events,  experi- 
ence shows  that  when  irrigations  are  properly  used,  the  posterior 
urethra,  if  it  does  not  escape  invasion,  does  not  show  any  mani- 
festations of  the  disease. 

Accepting  the  above  author's  most  reasonable  explanation  of 
the  etiology  of  posterior  gonorrhoea,  it  is  not  surprising  that 
remote  regions  and  organs  are  often  the  site  of  the  deposit  of 
gonococci.  As  mentioned  elsewhere,  there  is  hardly  a  soft 
tissue  of  the  organism  in  which  modern  investigation  has  not 
been  able  to  demonstrate  gonorrhoeal  infection. 

Among  the  manifestations  of  remote  gonorrhoeal  invasion, 
rheumatism  is  at  present  the  most  frequently  recognized.  In 
the  majority  of  cases  it  affects  only  one  joint,  and  among  these 
oftenest  the  knee.  Less  frequently  the  ankle,  wrist,  and  elbow 
are  the  site  of  gonorrhoeal  rheumatism. 

Gonorrhoeal  rheumatism  is  not  distinguishable  from  rheu- 
matism of  other  origin.  Neither  does  its  appearance,  while  a 
patient  has  gonorrhoea  of  the  urethra,  conjunctiva,  vagina,  or 
rectum,  prove  that  it  is  gonorrhoeal.  The  fever  and  sweating 
are  usually  higher  in  ordinary  rheumatism,  except  when  the  af- 
fected joint  becomes  the  site  of  pus  formation. 

When  rheumatism  of  any  kind  complicates  gonorrhoea  it 
should  be  treated  as  rheumatisms  usually  are.  While  this  is 
being  done,  irrigations  must  not  be  interrupted,  so  that  the 
gonococci,  which  may  be  the  provokers  of  the  rheumatism,  be 
eliminated  as  soon  as  possible. 

Skin  Diseases. — Taylor  says  that  he  has  many  times  seen 
patients  with  acute  and  declining  gonorrhoea  attacked  by  erup- 
tions resembling  scarlatina,  measles,  oedematous  erythema,  and 
urticaria.  In  some  instances  he  did  not  find  that  gastric  dis- 
turbances due  to  antiblennorrhagics  was  the  exciting  cause. 

Many   other    eminent    writers   have    reported  such  cases. 


116  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Among  these  Finger'  described  tliree  of  gonorrhoea  and  cystitis 
complicated  by  purpura  rlieumatica. 

Buschke/  groux)ing  his  own  observations  and  those  of  other 
writers,  "  first  mentions  simple  erythema,  which  usually  appears 
in  connection  with  gonorrhoeal  rheumatism,  epididymitis,  or 
other  localized  inflammatory  complication.  Cases  have  been 
recorded,  however,  of  a  febrile  erythematous  rash  in  gonorrhoea. 

The  second  group  is  made  up  of  urticaria  and  erythema 
nodosum.  The  fact  that  the  latter  form  of  eruption  may  com- 
plicate a  febrile  gonorrhoea  shows  that  it  is  not  a  mere  appanage 
of  polyarthritis,  but  is  most  likely  due  to  the  direct  action  of 
the  gonococcus. 

The  third  division  of  Buschke  is  made  up  of  hemorrhagic 
and  bullous  eruptions. 

The  fourth  and  last  division  consists  of  the  hyperkeratoses, 
and  has  hardly  before  been  mentioned  in  literature.  Buschke 
has  found  a  record  of  four  cases  which  he  considers  in  this  con- 
nection. In  a  case  originally  described  by  Chauffard,  for  ex- 
ample, there  were  horny  thickenings  upon  the  feet,  back,  penis, 
and  insides  of  thighs,  accompanying  a  general  gonorrhoeal  in- 
toxication. ^ 

Authorities  are  still  at  odds  as  to  the  explanation  of  these 
cutaneous  manifestations  of  gonorrhoea,  and  several  widely  dif- 
fering views  are  ably  maintained  in  controversy." 

My  own  studies  of  skin  complications  of  gonorrhoea  began 
after  I  had  commenced  the  use  of  irrigations.  None  of  the 
cases  so  treated  from  the  inception  had  any  dermal  trouble. 
Many  of  those  which  had  been  treated  before  by  internal  medi- 
cation or  hand  injections  or  both,  had  skin  diseases.  In  those 
in  which  the  skin  affections  could  not  be  traced  to  digestive  dis- 
turbances from  antiblennorrhagics,  they  appeared  to  have  no 
connection  with  gonorrhoeal  infection,  except  in  some  of  those 
conditions  mentioned  under  neuroses. 

Stricture.  — -Wossidlo'  defines  urethral  stricture  as  "  a  nar- 

1  Finger :  "  Ueber  Purpura  rheumatica  als  Komplication  blennorrliagisclier 
Prozesse."    Wiener  medicinische  Presse,  Nos.  9,  10,  and  11,  1880. 

^Buschke:  Archiv  fiir  Dermatologie  und  Syphilis,  Band  xlviii.,  No.  2, 
most  admirably  excerpted  by  the  Medical  Review  of  Reviews,  July  25th,  1899. 

^Wossidlo:  Die  Stricturen  der  Harnrohre  und  ihre  Behandlung,  Nau- 
mann,  Leipzig,  1898. 


COMPLICATIONS   AND   SEQUELS    OF   GONORRHCEA.        117 

rowing  of  tlie  urethral  lumen  and  reduction  of  its  normal  dila- 
tability,  produced  by  organic  changes  in  the  urethral  walls." 

Such  changes  are  usually  brought  about  by  a  gonorrhoea 
allowed  to  go  on  to  chronicity  through  lack  of  proper  treatment 
or  care.  Congenital  strictures,  however,  and  those  provoked 
by  traumatisms  (such  as  the  passage  of  a  rough  stone)  may 
complicate  gonorrhoea  as  seriously  as  can  acquired  strictures. 
They  can,  moreover,  by  the  same  cicatricial  tendency  to  con- 
traction, produce  all  the  disastrous  results  that  may  follow  the 
latter.  Infantile  lithiasis,  evidenced  by  painful  urination  and 
purulent  discharge,  containing  no  gonococci  and  afterward  for- 
gotten, may  often  be  the  cause  of  presumed  congenital  stricture. 

When  stricture  from  internal  or  external  causes  complicates 
gonorrhoea,  the  disease  will  persist  ordinarily  until  the  stricture 
is  cured.  Stricture  itself  is  too  vast  a  subject  to  be  even  outlined 
in  a  small  effort  like  this ;  its  influence  on  gonorrhoea,  which  is 
prone  to  aggravate  a  pre-existent  stricture  and  to  produce  new 
coarctations,  is  daily  evident. 

The  presence  of  stricture  in  no  wise  modifies  the  treatment 
of  .gonorrhoea  by  irrigations.  When  the  acute  manifestations 
of  gonorrhoea  have  yielded,  the  stricture  or  strictures  must  re- 
ceive attention,  as  will  be  sketched  under  the  head  of  Chronic 
Gonorrhoea. 

Traumatisms  of  the  Ueethra. — The  injuries  of  the  urethra 
that  may  complicate  gonorrhoea  are,  besides  those  mentioned 
under  Foreign  Bodies  and  Hsematuria,  such  as  may  be  pro- 
duced by  faulty  circumcision. 

M.  A.  Wasiliew,'  citing  Bergson,  Ploss,  and  Joly,  shows  that 
this  operation  was  performed  by  the  ancient  Egyptians  and 
Phoenicians.  To-day  ritual  circumcision  is  done  only  by  Jews, 
Mohammedans,  and  a  number  of  savage  tribes. 

The  American  and  Eussian  Jews  cut  off  the  preputial  in- 
tegument with  a  small  knife,  and  tear  the  mucous  fold  with  the 
fingers.  The  knife  may  injure  the  glans  and  the  part  of  the 
urethra  it  contains;  efforts  to  split  a  firmly  adherent  mucosa 
with  the  pulp  of  the  index  fingers  and  thumb  nails  may  tear 
open  the  fossa. 


'  Wasiliew  :  Die  Traumen  der  manDlichen  Harnrohre,  Hirschwald,  Berlin, 
1899. 


118  THE    IRRIGATION   TREATMENT    OF   GONORRHCEA. 

In  Germany  and  Hungary,  so  I  am  informed,  many  ritual 
circumcisers  maintain  the  right  thumb  nail  long  and  trimmed 
for  the  operation;  others  use  a  silver  ring-shaped  attachment 
with  a  flat,  finger-nail-like  projection,  to  slip  over  the  thumb 
when  the  operation  is  to  be  performed. 

At  least  one  of  the  native  tribes,  Los  Lacantunes,  of  that 
region  of  Guatemala  that  has  been  but  partly  explored,  use  an 
obsidian  for  the  same  purpose. 

Bamon  Guiteras'  is  of  the  opinion  that  stricture  of  the 
meatus  is  most  frequent  with  those  circumcised  in  infancy. 
Since  having  attention  called  to  this  point,  I  searched  my 
records  and  found  that  I  performed  far  more  meatotomies  on 
those  circumcised  in  early  life  than  on  others.  If  this  is  not 
a  mere  coincidence,  it  is  hardly  explicable  by  nature  contracting 
the  meatus  to  protect  the  urethra.  It  seems  more  likely  to  be 
attributable  to  the  crude  methods  employed  by  the  Mohelim  or 
Mauhelim  (ritualistic  circumcisers). 

Every  physician  who  has  circumcised  many  infants  knows 
that  the  lips  of  the  meatus  are  found  pouting.  As  the  ritualistic 
circurncisers  cut  or  jjinch  off  the  foreskin  close  to  the  meatus, 
it  is  readily  appreciable  how  they  can  remove  with  it  a  part  of 
the  pouting  lips.  The  resulting  cicatrix  naturally  contracts 
and  so  produces  the  stricture.  Among  those  who  present  no 
contraction  of  the  meatus,  slight  radiating  marks  suggest  the 
possibility  of  a  small  tip  of  the  meatus  liaving  been  removed. 

Disregard  for  aseijsis  in  ritualistic  circumcision  has  caused 
many,  and  among  them  devout  Jews,  to  inveigh  against  the  op- 
eration. Erysipelas,  syphilis,  and  tuberculosis  are  frequently 
reported  in  support  of  this  objection.  In  France  a  sanitary  law 
was  passed  at  the  beginning  of  1899  prohibiting  circumcision, 
except  it  be  in  the  presence  of  a  physician.  While  the  intent 
of  this  law  is  manifest,  its  execution  is  likely  to  fall  far  short 
of  its  purpose,  as  must  be  evident  to  those  who  from  sad  ex- 
perience know  the -difficulty  of  securing  asepsis  in  even  trained 
assistants  and  nurses. 

Eegarding  injuries  to  the  urethra  from  circumcision,  Sascke'' 

1  Guiteras  :  "A  Review  of  the  Principal  Features  of  Urethral  Stricture." 
Medical  Review  of  Reviews,  January  25th,  1899. 

'^Sascke:  "Betrachtliche  Verletzung  der  Harnrohre."  Schmidt's  Jahr- 
bticher,  vol.  Iv.,  1847. 


COMPLICATIONS   AND   SEQUELS   OF   GONORRHCEA.        119 

reports  a  young  Jew  whose  anterior  half  of  the  glans  was  miss- 
ing. The  meatus  was  at  the  lower  surface,  and  behind  this  a 
second  orifice  emitted  the  urine.  It  seems,  however,  that  in  this 
case  the  mutilation  complicated  a  pre-existing  deformity, 

A  patient  referred  to  me  for  chronic  gonorrhoea  had  had 
over  four-fifths  of  the  right  half  of  his  glans  torn  off  during 
ritualistic  circumcision.  The  left  side  of  the  fossa  was  exposed. 
From  the  right  coronary  margin  three  fleshy  projections  hung. 
The  consequence  of  this  deformity  doubtless  contributed  in 
making  his  gonorrhoea  most  persistent. 

A  most  aggravated  case  of  urethral  traumatism  from  ex- 
ternal violence  was  in  a  young  man  whose  penis  a  prostitute 
had  bitten  while,  as  he  said,  both  were  drunk.  Singularly 
enough,  the  upper  surface  of  the  middle  third  of  the  penis 
showed  only  slight  bruises  from  the  teeth;  the  lower  central 
incisors  had  evidently  been  sharper,  for  they  penetrated  the 
urethra  and  had  sunk  into  the  corpora  cavernosa.  Permanent 
catheterization  was  at  once  employed,  but  as  the  wound  soon 
manifested  syphilitic  infection  attempts  at  repair  have  thus  far 
proved  futile. 

Injuries  to  the  urethra  from  within,  such  as  follow  violent 
instrumentation,  false  passages,  tears  of  the  mucosa,  may  com- 
plicate gonorrhoea.  When  irrigations  have  reduced  the  inflam- 
mation and  discharge  to  a  minimum,  these  injuries  should  be 
sought  by  the  urethroscope  and  treated  as  their  especial  char- 
acter may  require. 

Yesiculitis  Seminalis  (Gonocystitis) . — If  Fuller'  had  done 
nothing  else  than  develop  the  pathology  and  rational  treatment 
of  inflammation  of  the  seminal  vesicles,  his  studies  of  this  dis- 
ease alone  would  suffice  to  place  the  profession  under  deep  ob- 
ligations to  him. 

With  a  view  to  refreshing  memory  on  the  precise  location  of 
these  organs,  whose  infection  is  far  more  frequent  than  ordi- 
narily recognized,  a  schematic  drawing  may  be  borrowed  from 
Stewart,^  elucidated  with  Lewis'  ^  concise  description  of  the 
seminal  vesicles  which  is  here  condensed :  The  vasa  deferentia 

'  Fuller  :  Disorders  of  the  Male  Sexual  Organs,  Lea,  Philadelphia,  1896. 
2  Stewart :  Diseases  of  the  Urethra,  William  Wood  &  Company. 
2  Lewis :    "  Seminal  Vesiculitis  as   an  Obscure    and   Elusive   Disease." 
Medical  Age,  June  25th,  1897. 


120 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


carry  the  spermatozoa  from  the  testicles,  through  the  inguinal 
canals,  into  the  pelvic  cavity,  converging  behind  the  bladder  and 
almost  touching  each  other  behind  the  prostate.  The  seminal 
vesicles  lie  against  the  posterior  surface  of  the  bladder,  just 
beyond  the  convergence  of  the  vasa,  which  conduct  the  sperma- 
tozoa into  the  vesicles.  There  the  fluid  secretion  of  the  vasa 
keeps  them  alive.  At  opportune  moments  (coitus  or  nocturnal 
emission)  the  spermatozoa  are  thrown  out  of  the  vesicles  through 
the  ejaculatory  duct,  which  perforates  the  prostate,  into  the  pos- 


FiG.  39.— Location  of  the  Seminal  Vesicles  (from  Stewart's  "Diseases  of  the  Urethra  "). 


terior  urethra,  where  they  are  mixed  with  prostatic  juice,  and 
whence  they  are  ejected  by  the  spasmodic  contractions  of  ejacu- 
lation. 

It  consequently  is  clear  that  the  finger  inserted  into  the 
rectum  will  feel  the  seminal  vesicles  immediately  above  the 
prostate  and  projecting  to  either  side  of  the  bladder.  In  health, 
however,  these  soft  little  pouches  are  difficult  and  often  impos- 
sible to  find. 

In  view  of  the  fact  that  the  ejaculatory  duct  is  so  short  and 
almost  straight,  it  is  strange  that  seminal  vesiculitis  does  not 
more  frequently  complicate  gonorrhoea.  As,  however,  acute 
gonocystitis,  as  Gouley  aptly  calls  the  disease,  fortunately  tends 
to  resolution,  it  may  be  overlooked  in  very  many  gonorrhoeas. 


COMPLICATIOXS    AND    SEQUELS    OF    GOXORRHCEA.        121 

Moreover,  tlie  close  resemblance  of  its  symptoms  to  those  of 
posterior  urethritis  and  prostatitis  may  account  for  its  relatively 
rare  discovery.  If  every  patient  with  gonorrhoea  were  subjected 
to  digital  examination  per  rectum,  infection  of  the  seminal  ves- 
icles would  be  better  understood  and  its  often  disastrous  con- 
sequences avoided. 

The  symptoms  may  be  ushered  in  by  a  mere  sense  of  weight 
in  or  about  the  perineum.  This  soon  changes  to  dull  or  throb- 
bing pain  in  this  region  and  that  within  the  anus  and  the  bladder. 
Rectal  and  vesical  tenesmus  may  become  very  intense.  All 
these  symptoms  increase  while  urine  accumulates  in  the  bladder ; 
the  pain  then  may  be  referred  to  the  region  of  the  glans  or  the 
root  of  the  penis,  or  both.  The  constitutional  disturbance  is 
often  quite  marked;  anorexia,  even  nausea,  may  accompany  the 
beginning  of  the  disease,  while  decided  chills  and  fever  may 
cause  an  error  of  diagnosis. 

Certainty  of  differentiation,  principally  from  posterior  ure- 
thritis, is  obtainable  only  by  rectal  examination.  The  presence 
of  a  swollen,  painful  jjrostate  should  not  be  accepted  as  conclud- 
ing a  diagnosis.  The  finger  passed  beyond  this  gland  should 
seek  the  seminal  vesicles  which,  if  involved,  will  be  found 
"  much  enlarged  in  all  directions  in  the  shaj^e  of  a  distended 
leech,  hot,  brawny,  and  exquisitely  tender  "  (Taylor). 

Further  development  of  the  disease  can  cause  a  pulpy  con- 
fluence of  the  vesicles  of  both  sides,  rendering  their  delineation 
imijossible.  They  may  then  appear  as  if  overhanging  the  pros- 
tate like  a  large,  flabby  mass. 

With  the  progress  of  vesiculitis  the  patient  presents  all  the 
appearances  of  severe  illness  associated  with  acute  sufferings. 
The  pains  in  the  perineum,  rectum,  and  bladder  become  intensi- 
fied, and  extend  to  the  sacrum,  the  coccyx,  the  hip-joint,  down 
the  sciatic  nerve,  sometimes  up  to  the  diaphragm,  making  even 
breathing  painful.  The  local  pains  are  increased  by  urination, 
which  is  frequent;  but  the  pain,  if  there  is  any  after  urina- 
tion, is  not  so  severe  nor  so  prolonged  as  that  of  posterior 
urethritis. 

Examination  of  the  urine  may  be  misleading,  unless  speci- 
mens of  the  first  morning  urine  or  that  passed  at  the  end  of 
defecation  is  used.  At  other  times  the  urine  may  appear  normal. 
The  properly  selected  specimen  will  contain,  according  to  the 


122  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

intensity  of  the  involvement,  pus  corpuscles,  red  blood  corpus- 
cles, epitlielia  from  the  ejaculatory  ducts,  epithelia  from  the 
prostate,  mucous  casts,  and  spermatozoa.  Among  the  latter 
manj  a  one  will  be  found  with  a  rounded  enlarged  head  whose 
pelluciditv  has  changed  to  a  granular  appearance,  making  the 
diseased  spermatozoon  look  like  a  tailed  pus  corpuscle.  If  the 
gonocjstitis  is  gonorrhoeal,  gonococci  will  be  present  in  the 
specimen.  The  greater  the  chronicitj  of  the  case,  the  greater 
will  be  the  number  of  the  fat  globules.  Fuller  {op.  cit.)  holds 
that  in  about  one-third  of  the  cases  of  seminal  vesiculitis  the 
disease  is  tuberculous.  "WTiile  all  deference  is  due  to  Fuller's 
wide  researches,  this  large  number  of  tuberculous  invasions  of 
the  seminal  vesicles  does  not  coincide  with  the  experience  of 
others,  that  of  the  present  writer  included.  Still,  Fuller's 
warning  should  never  be  left  out  of  mind. 

Heitzmann  {ojj.  cit.)  always  finds  prostatic  epithelia  with 
microscopic  evidences .  of  gonocystitis,  from  which  he  deduces 
that  the  prostate  is  inflamed  when  the  seminal  vesicles  are.  For 
self-evident  reasons  (see  Fig.  39,  page  120)  it  would  be  practically 
impossible  for  the  prostate  to  escape  such  infection.  But  as 
the  disease  of  the  vesicles  may  overshadow  the  latter,  it  may 
elude  observation. 

Defecation,  in  seminal  vesiculitis,  is  often  as  painful  as  is 
urination.  It  may  be  associated  with  intense  tenesmus  of  the 
rectum  and  of  the  bladder. 

Unless  sleep  is  disturbed  by  painful  erections  or  emissions, 
it  may  be  very  prolonged.  Despite  its  length,  the  patient  is  as 
fatigued  when  he  awakes  as  when  he  retired. 

If  the  patient  has  nocturnal  emissions,  they  may  be  bloody 
or  of  a  chocolate  color,  from  the  admixture  of  blood. 

When  the  ejaculatory  duct  is  not  fii-mly  agglutinated,  the 
seminal  vesicle  may  be  emptied  of  much  or  all  of  its  pus  by 
strippings  through  the  rectum.  The  remainder  of  the  treat- 
ment is  necessarily  similar  to  that  advised  for  prostatitis. 

If  acute  vesiculitis  does  not  go  on  to  resolution  or  is  not  re- 
lieved by  treatment,  it  may  go  over  into  chronic  gonocystitis  or 
abscess  may  form,  with  all  the  dangers  of  invasion  of  other 
structures. 

Abscess  of  the  seminal  vesicles  should  be  promptly  emptied 
through  the  perineum  or  the  rectum.     In  making  the  long  free 


COMPLICATIONS   AKD   SEQUELS    OF   GONORRHCEA.        123 

incision  through  the  anterior  rectal  wall  for  extensive  abscess, 
as  advised  by  Goule j,  the  cavity  should  be  carefully  packed  and 
asepsis  of  the  region  observed  as  cautiously  as  possible. 

An  attempt  to  study  chronic  seminal  vesiculitis  in  such  brief 
form  as  would  be  admissible  here  could  not  but  prove  mislead- 
ing. The  reader  is  therefore  referred  to  the  more  exhaustive 
works  of  Fuller,  Gouley,  Taylor,  White  and  Martin,  and  others 
for  clear,  complete  discussion  of  the  subject. 

This  perfunctory  disposal  of  chronic  seminal  vesiculitis 
should  not  lead  to  a  light  consideration  of  the  disease.  The 
vast  array  of  symptoms,  direct  and  reflex,  which  it  produces 
makes  it  worthy  of  most  serious  attention,  as  do  the  dangers  to 
which  it  exposes  the  patient.  Moreover,  when  due  to  gonor- 
rhoea, as  it  very  often  is,  it  will  explain  many  cases  of  apparently 
frequent  recurrences  of  the  disease.  Indeed,  when  a  presumably 
fresh  gonorrhoea  presents  in  less  than  two  or  more  than  ten  days 
after  coitus,  the  physician  would  be  derelict  in  his  duty  if  he 
did  not  interrogate  the  seminal  vesicles. 

TJretheo-Peostatio  Intectign  by  the  Nogues-Wasseemann 
DiPLOCOCCUS. —While  this  form  of  genito-urinary  infection  is 
not  a  complication  of  gonorrhoea,  it  is  outlined  here  for  con-, 
venience  of  differentiation.  This  urethro-prostatic  trouble  may 
be  mistaken  for  cystitis,  urethro-cystitis,  and  prostatitis.  Paul 
Nogues  and  Melville  Wassermann'  describe  the  etiological 
microbe  which  they  discovered  as  resembling  the  gonococcus 
in  form,  dimensions,  staining  and  decolorization  by  Gram's 
method  so  closely  that  many  authors  would  not  hesitate  to  class 
it  with  Lustgarten  and  Mannaberg's  pseudo-gonococci.  They 
insist  that  all  the  diplococci  so  grouped  can  be  differentiated  by 
careful  examination. 

Nogues  and  Wasserm'ann  describe  the  symptoms  of  urethro- 
prostatic  infection  by  their  micro-organism  in  a  case  from 
Guyon's  service  in  the  Hopital  Necker: 

The  patient,  aged  42,  had  no  disease  except  syphilis,  con- 
tracted many  years  ago.  Eighteen  months  before  being  treated 
at  the  Necker,  he  had  had  vague  pains  in  the  region  of  the  peri- 
neum and  of  the  anus.     Twelve  days  subsequently  he  observed 

'  Nogu6s  et  Wassermann  :  "  Infection  Ur^thro-Prostatique,  due  k  un  micro- 
organisme  particulier."  Annales  des  Maladies  des  Organes  G^nito-Urinaires, 
July,  1899. 


124o  THE   IRRIGATION   TREATMENT    OF    GONORRHCEA. 

an  oozing  from  the  urethra.  This  oozing  never  assumed  the 
proportions  of  a  true  blennorrhoea,  he  had  no  painful  urination 
nor  nocturnal  erections.  The  only  functional  symptom  was  the 
anal  pain  mentioned  above.  For  six  months  he  was  treated,  by 
washings  with  boric  acid  and  santal  oil  internallj'.  The  next 
physician  he  consulted  diagnosed  prostatitis  and  employed  irri- 
gations of  potassic  permanganate  and  prostatic  massage.  No 
change  in  the  condition  resulted  in  the  beginning;  soon,  how- 
ever, vesical  manifestations  aj^peared- — the  patient  urinated 
every  two  hours  during  the  day  and  four  times  at  night.  In 
this  condition  he  sought  Professor  Guyon's  advice.  The 
urethral  discharge  was  then  minimal,  but  a  few  slightly  colored 
spots  stained  the  shirt;  the  urine  was  acid  and  clear,  but  the 
first  urine  emitted  contained  numerous  dense  and  heavy  fila- 
ments. The  urethra  was  found  in  good  condition,  the  bladder 
of  nearly  normal  capacity.  The  prostate  was  in  almost  com- 
plete health,  but  the  urine  voided  immediately  after  massage 
was  decidedly  turbid.  In  this  specimen  Nogues  and  Wasser- 
mann  found  their  microbe. 

After  an  instillation  of  silver  nitrate  into  the  prostatic  por- 
tion by  Guyon's  method,  the  urine  almost  recovered  its  trans- 
parence; very  careful  microscopic  examination  did  not  reveal 
any  bacteria  whatever,  and  two  tubes  of  agar  and  of  bouillon 
sown  with  the  specimen  remained  sterile.  The  cure  was  verified 
two  weeks  later  by  a  second  bacteriological  examination  which 
gave  a  negative  result. 

The  authors,  after  most  exhaustive  histological  and  bacterio- 
logical series  of  experiments,  including  cultures  on  all  accepted 
media  of  the  turbid  urine  with  an  abundant  whitish  sediment, 
sum  up  the  characteristics  of  their  microbe  as  follows : 

A  diplococcus,  within  and  outside  the  leucocytes,  not  in 
specific  grouping,  readily  decolorizable  by  Gram's  method; 
easily  and  abundantly  culturable  on  all  the  ordinary  media  ex- 
cept on  potato;  does  not  liquefy  gelatin,  indifferent  in  the 
presence  of  oxj^gen  and  of  rapid  growth  in  anaerobic  condition ; 
apparently  with  no  power  to  decompose  urea. 

They  conclude  that  the  diplococcus  they  describe  is  the  in- 
fectious agent  of  a  form  of  urethro-prostatitis  and  that  it  can  be 
thoroughly  differentiated  from  the  gonococcus  by  culture. 


CHRONIC   GONORRHCEA.  125 


VIII.    CHUONIC  GONORRHCEA. 

Under  tlie  treatment  pursued  before  irrigations  were  estab- 
lished, six  weeks  was  deemed  tlie  duration  of  an  acute  gonor- 
rhoea. If  it  proceeded  beyond  sis  weeks,  it  was  considered  to 
have  gone  over  into  a  chronic  condition.  This  chronicity, 
however,  was  often  associated  with  all  the  symptoms  of  the 
acute  attack. 

Goldberg's  statistics  (quoted  on  page  1)  compiled  from  the 
works  of  all  who  wrote  on  irrigations,  whether  apj)rovingly 
or  disapprovingly,  show  that  ninety  per  cent,  of  the  patients  re- 
cover within  fourteen  days.  It  is  therefore  equally  proper  to 
hold  that  a  case  of  gonorrhoea  not  entirely  cured  within  two 
weeks  must  be  considered  a  chronic  clap. 

Janet,  to  whom  all  the  credit  is  due  for  popularizing  the 
irrigation  treatment,  advises  a  second  series  of  irrigations  after 
the  first  series,  when  that  has  not  succeeded.  The  second  series 
of  irrigations  with  solutions  of  potassic  permanganate  as  advo- 
cated by  Janet  is  as  follows : 

First  day,  first  visit,      Anterior  irrigation 1  :  3,000 

First  day,  7  p.m.  Anterior  irrigation 1  :  6,000 

Second  day,  9  a.m.         Intravesical  irrigation 1 :  4,000 

Second  day,  7  p.m.         Anterior  irrigation 1 :  4,000 

Tliird  day,  7  p.m.  Anterior  irrigation 1 :  2,000 

Fourtli  day,  9  a.m.         Intravesical  irrigation 1  :  3,000 

Fourth  day,  7  p.m.  Anterior  irrigation 1 :  2,000 

Fifth  day,  7  p.m.         i  Intravesical  irrigation 1 :  3,000 

I  Anterior  irrigation 1 : 1,000 

Sixth  day,  7  p.bi.  Anterior  irrigation 1  : 1,000 

Seventh  day,  7  p.m.        Anterior  irrigation 1 : 1,000 

Eighth  day,  7  p.m.      \  Intravesical  irrigation 1 :  3,000 

(Anterior  irrigation 1:1,000 

In  offering  the  above  formulary,  no  thought  is  conveyed  that 
it  will  cure  every  chronic  gonorrhoea.  Even  if  the  clap  is  un- 
complicated, the  solutions  may  have  to  be  materially  modified 
to  meet  the  individual  peculiarities  of  each  case.  The  solutions 
advised,  however,  meet  the  average  cases. 

Furthermore,  this  formulary  will  serve  admirably  in  most 
gonorrhoeas  which  appear  without  acute  manifestations  (chro- 
niques  d'emhUe,  Guiard)  and  which  are  so  often  erroneously 
called  "light  attacks." 


126  THE   IRRIGATION   TREATMENT    OF   GONORRHCEA. 

Tlie  majority  of  cases,  however,  require  most  scrupulous 
searcli  for  tlie  conditions  tliat  cause  their  progression  into 
•chronicity. 

In  an  effort  like  this  none  but  the  barest  outlines  of  pathol- 
ogy can  be  sketched,  and  indeed,  none  of  these  can  find  jplace 
except  those  essential  to  an  intelligent  comprehension  of  the 
treatment  advocated.  The  writers  who  have  labored  and  are 
laboring  so  industriously  and  well  in  this,  the  most  imjjortant 
department,  of  genito-urinary  diseases,  can  receive  but  scant 
attention.  No  lack  of  appreciation  is  conveyed  thereby.  As 
Oberlaender^  said  five  years  ago :  "  The  literature  of  chronic 
urethritis  has  grown  to  monstrous  proportions."  The  additions 
to  this  literature  since  then  are  if  anything  greater  in  number  than 
those  which  preceded  Oberlaender's  comment;  hence  the  hope- 
lessness of  attempting  even  approximate  justice  to  the  authors. 

The  principal  conditions  that  predispose  a  patient  to  the 
establishment  of  a  chronic  gonorrhoea  are  reduced  vital  resist- 
ance, lax  urethral  mucosa,  phthisis,  diabetes,  phimosis,  agglu- 
tination of  the  prepuce  to  the  glans,  tight  meatus,  a  narrow 
urethra,  deformities  of  the  glans,  para-urethral  fistufe  and  re- 
sidual defects  from  former  gonorrhoeas,  "  be  they  ever  so  minute 
and  often  not  evident  to  the  inexperienced  urethroscopist " 
(Oberlaender),  In  many  instances  none  of  these  predisposing 
elements  are  found  to  explain  the  progress  into  chronicity;  in. 
any  given  case  in  which  this  occurs,  cure  is  not  likely  to  be  ob- 
tained until  the  cause  is  found  and  removed. 

The  causes  of  the  transition  of  gonorrhoea  into  the  chronic 
state,  are  summed  up  by  Guiard  ^  in  his  brilliant  and  exhaustive 
work  on  the  subject.  With  slight  modification  from  this  author, 
they  may  be  cited  as :  (1)  congenital  or  acquired  deformities ;  (2) 
the  patient's  constitutional  condition;  (3)  misdirected  or  in- 
sufficient initial  treatment;  (4)  infractions  of  hygienic  precau- 
tions ;    (5)  over-treatment. 

The  two  first-named  have  been  briefly  mentioned  above. 
They  are  discussed  somewhat  more  in  detail  in  Chapter  YII. 
(Complications  of  Gonorrhoea). 

'Oberlaender:  "Die  chronischen  Erkrankungen  der  mannlicben  Harn- 
rbhre."  Klinisches  Handbuch  der  Harn-  und  Sexualorgane,  vol.  iii.,  Vogel, 
Leipzig,  1894. 

-  Guiard :  Les  urethrites  cbroniques  cbez  rbomme,  1898,  Rueff,  Paris. 


CHRONIC    GONOREHCEA.  127 

As  outlined  under  the  head  of  acute  gonorrhoea,  irrigations 
to  be  effective,  must  be  promptly  and  energetically  instituted 
as  soon  as  possible  after  inception  of  the  disease.  But  irriga- 
tions will  certainly  be  misdirected  and  thwart  the  object  in 
view  if  the  physician  were  to  mistake  force  and  violence  for 
promptness  and  energ}^  The  column  of  fluid,  if  bruskly  sent 
into  an  exquisitely  inflamed  urethra,  cannot  but  damage  it; 
lesions  can  easily  be  caused  thereby,  directly  inviting  invasion 
of  the  deeper  structures  and  thence  of  the  adnexa  and  the  entire 
organism.  Therefore,  while  all  uncomplicated  and  most  com- 
plicated gonorrhoeas  must  and  should  be  treated  by  the  general 
practitioner,  none  should  touch  them  save  those  who  are  char- 
acterized by  innate  and  carefully  cultivated  delicacy  of  manipu- 
lation. Only  those  so  endowed  are  able  to  avoid  misdirecting 
even  the  best  intended  efforts. 

Insufficient  initial  treatment  is  likely  to  obtain  in  the  hands 
of  physicians  whose  delicacy  of  touch  is  above  criticism,  but 
who  lack  adequate  firmness  of  purpose.  While  these  will  not 
sin  by  injuring  the  inflamed  urethra  they,  through  timorousness, 
are  prone  to  allow  the  disease  to  gain  mastery  over  the  infected 
region.     This  extreme  is  quite  as  reprehensible  as  the  other. 

An  exceedingly  frequent  element  for  the  production  of 
chronic  gonorrhoea,  entirely  beyond  the  physician's  responsi- 
bilitj- ,  is  in  the  hygienic  and  dietary  infractions  which  patients 
commit.  In  Chapter  VI.  (Constitutional  and  Accessory  Treat- 
ment) an  endeavor  is  made  to  outline  the  hygienic  and  dietary 
precautions  that  are  necessary  for  the  successful  treatment  of 
gonorrhoea.  If  the  physician,  for  any  reason,  cannot  obtain 
such  control  over  his  patient  that  the  latter  will  follow  these  sim- 
ple instructions  or  apx^reciate  the  dangers  of  their  infraction,  he 
will  wisely  recommend  to  him  the  study  of  James  Foster  Scott's' 
book.  Should  the  patient's  inferior  intelligence  or  lack  of  ap- 
plication not  permit  him  to  grasp  the  value  of  Scott's  excellent 
work,  he  may  be  advised  to  read  a  small  effort  in  the  same 
direction.  Its  author^  will  not  object  if  his  name  is  erased 
from  the  article  before  it  is  handed  to  the  patient. 

'  Scott :  The  Sexual  Instinct ;  Its  Use  and  Dangers  as  Affecting  Heredity 
and  Morals,  Treat,  New  York,  1899. 

■^"Advice  to  Gonorrhceai  Patients."  Philadelphia  Medical  Journal,  July 
8th,  1899. 


128  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

Excessive  treatment  cannot  onlj^  assure  a  gonorrhoea  becom- 
ing clironic,  but  also  tends  to  perpetuate  a  chronic  clap  indefi- 
nitely. In  Chapter  XIV.  (The  Proofs  of  Cure  of  Gonorrhoea) 
the  indications  for  discontinuance  of  treatment  are  detailed. 

The  local  pathological  conditions  which  maintain  a  chronic 
gonorrhoea  have  been  and  are  made  the  objects  of  special  in- 
vestigations by  an  immense  array  of  learned  men.  To  even 
quote  their  names  and  outline  their  results  would  require  a 
large  volume. 

For  the  general  practitioner's  purpose  it  may  suffice  to  be- 
gin the  study  of  chronic  gonorrhoea  by  attaching  its  cause  to: 
(1)  epithelial  disturbance;  (2)  infiltration  of  the  mucosa;  (3)  in- 
volvement of  the  urethral  glands ;  (4)  infection  of  the  adnexa. 

While  precise  distinction  of  the  three  first-mentioned  condi- 
tions is  obtainable  only  by  the  urethroscope,  it  can  hardly  be 
expected  that  any  but  those  with  a  very  large  general  practice 
will  avail  themselves  of  this  instrument  of  precision.  Those 
who  desire  to  instruct  themselves  in  urethroscopy  wdll  fijid 
elementar}^  outlines  thereof  in  Chapter  XIII.  (Urethroscopy). 

A  studj^  of  the  symptoms  of  chronic  gonorrhoea  is,  however, 
open  to  even  the  least  experienced.  An  effort  will  be  made  to 
depict  those  that  are  most  directly  related  to  therapeutic  sug- 
gestions. For  easy  reference  they  are  arranged  in  alphabetical 
order.  Necessarily,  with  a  view  to  differentiation,  this  list  must 
include  some  symptoms  not  due  to  chronic  gonorrhoea. 

Absence  op  Symptoms — see  Chapter  XIV.  (Proofs  of  Cure  of 
Gonorrhoea). 

Apparent  Asperml\. — Quite  a  number  of  patients  complain, 
long  after  external  evidences  of  gonorrhoea  have  passed  off,  that 
they  experience  little  or  no  sensation  at  the  conclusion  of  the 
sexual  act,  no  matter  how  prolonged  it  was.  When  withdrawing 
the  penis  at  the  feeble  conclusion  of  the  act,  nothing  is  seen  to 
escape  from  the  meatus.  Manifestly,  unless  the  case  be  one  of 
true  aspermia,  swelling  of  the  posterior  urethra  directs  the 
semen  into  the  bladder,  instead  as  normally,  through  the  com- 
pressor. The  next  urination  then  carries  with  it  the  semen  that 
should  have  been  forcibly  ejected  in  coitus. 

Some  of  these  patients,  who  are  called  "  trompeurs  "  (cheat- 
ers) in  French  literature,  will  confess  to  having  employed  arti- 
fices to  prolong  the  sexual  act  or  to  prevent  pregnancy.     These 


CHRONIC    GONORRHCEA.  129 

artifices  embrace  digital  compression  of  tlie  urethra,  constriction 
at  the  peno-scrotal  juncture  b}^  a  rubber  band,  or  a  species  of 
mental  coercion  by  means  of  which  the  orgasm  is  arrested  just 
before  ejaculation.  The  first  urine  passed  after  such  coitus  will 
be  found  to  contain  an  abundance  of  semen. 

Defecation  and  Ubination  Drop.  — Very  many  patients  have 
no  discharge  whatever,  but  during  or  after  defecation  or  after 
urination  a  thick  white  drop  appears  at  the  meatus.  The  man- 
ner in  which  this  drop  appears  at  once  suggests  a  urination — ■ 
or  defecation — spermatorrhoea.  Indeed,  these  may  coexist  with 
the  manifestation  which  I  have  named  as  above. 

Like  urination — or  defecation — spermatorrhoea,  this  drop  is 
sometimes  attributed  to  expression  of  a  diseased  prostate  or 
posterior  urethra,  by  the  pressure  of  lumps  of  hard  faeces  upon 
these  organs  in  their  passage  through  the  lower  rectum.  The 
anatomical  relations  of  this  region  prevent  a  fsecal  bolus,  which 
can  at  all  pass  the  anus,  from  exercising  sufiicient  pressure  upon 
the  prostate  or  posterior  urethra  to  expel  their  secretions. 
The  fgecal  mass,  however,  if  hard,  stimulates  voluntary  contrac- 
tions of  the  rectal  and  urethral  detrusors,  and  these,  by  forcible 
compression  of  the  prostate  and  posterior  urethra,  cause  them 
to  yield  some  of  their  contents. 

Macroscopically,  these  drops  differ  from  those  of  spermator- 
rhoea in  not  proving  tenuous — i.e.,  they  cannot  be  drawn  out 
in  such  long  filaments.  Moreover,  they  dry  in  concretions  re- 
sembling phosphatic  calculi.  When  fresh,  and  pressed  or 
rubbed  between  two  cover-glasses  they  convey  a  sensation  as  if 
they  contained  very  fine  sand. 

Microscopically,  these  drojjs  show  pus  in  minute  quantity, 
much  mucus,  epithelium,  and  occasionally  gonococci.  The  grit- 
like substance  has  the  appearance  of  little  globules,  resembling 
■cocci.  If  acetic  or  nitric  acid  is  added  to  them,  they  dissolve 
with  the  escape  of  bubbles  of  gas. 

If  spermatozoa  are  found,  the  case  may  be  one  of  pure  urina- 
tion or  defecation  spermatorrhoea ;  their  presence,  however,  does 
not  exclude  the  coincidence  of  gonorrhoeal  prostatitis  or  posterior 
urethritis. 

Dischaege.— In  chronic  gonorrhoea  the  discharge  may  vary 
from  a  slight,  glairy  excess  of  moisture,  expressible  to  the  meatus 
with  difficulty,  to  free,  continual,  or  intermittent  discharges. 
9 


130  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

The  cliscliarge,  whatever  its  character,  may  be  the  only  symp- 
tom which  the  patient  observes.  Some  patients  are  singularly 
indifferent  to  this  manifestation  of  disease  when  it  gives  them 
no  inconvenience  beyond  filthiness;  the  majority,  however,  are 
mentally  distressed,  and  in  consequence  physically  disturbed, 
by  an  excess  of  moisture  that  does  not  even  agglutinate  the 
meatus.  Whether  this  is  on  a  purely  aesthetic  score  or  due  to  a 
specific  lasting  influence  of  gonococci  toxins  on  the  nervous 
system,  is  one  of  the  questions  neurologists  still  have  to  solve. 

Whatever  the  character  of  the  discharge,  its  contents  and 
origin  must  be  ascertained.  Many  microscopical  examinations 
may  be  made  without  discovering  any  noxious  bacteria.  This 
does  not  entitle  the  physician  to  assert  that  none  exist  in  the 
patient's  genital  apparatus  (see  Chapter  XIV.,  Proofs  of  Cure 
of  Gonorrhoea).  Whether  gonococci,  with  or  without  other 
bacteria,  present  in  the  slight  or  copious,  permanent,  intermit- 
tent or  recurrent  discharge,  or  if  none  are  found,  the  origin  of 
the  discharge,  i.e.,  the  diseased  region  or  regions  and  the  char- 
acter of  the  disease,  must  be  ascertained.  The  discharge  itself 
is  not  characteristic  of  its  source.  While  it  can  be  determined 
by  the  kind  or  kinds  of  epithelia  found,  it  is  always  well  to  give 
equal  weight  to  the  clinical  manifestations.  These  are  outlined, 
as  are  the  methods  for  eliciting  them,  in  Chapter  VII.,  on  the 
Complications  of  Gonorrhoea. 

For  convenient  reference,  and  until  a  better  arrangement  is 
offered,  I  submit  the  following  description  of  urethral  dis- 
charges, which  may  be :  continuous ;  in  the  mornings  only ;  in- 
termittent during  the  day ;  intermittent  with  several  days',  weeks' 
or  months'  interval  (recurrent  gonorrhoea) ;  mixed  with  the  last 
portion  of  urine,  or  immediately  after  urination  (gonorrhoeic 
and  other  prostatorrhoea) . 

In  regard  to  color  and  consistence,  it  may  be :  watery,  al- 
buminoid, rice-water,  grayish,  thin  white,  thick  white,  thin  yel- 
low, thick  yellow,  thick  greenish-j'ellow,  thick  bloody. 

These  discharges  may  be  mixed,  as  for  instance  the  grayish 
discharge  may  be  mottled  with  spots  of  white,  yellow,  or  green, 
or  it  may  be  streaked  with  these  colors. 

I  may  be  permitted  to  emphasize  that  this  classification  of 
the  discharge  of  chronic  gonorrhoea  is  offered  solely  for  con- 
venience of  recording. 


CHRONIC   GONORRHOEA.  131 

A  form  of  discliarge  characteristic  of  prostatic  involvement, 
and  not  mentioned  above,  has  a  tendency  to  be  drawn  out  in 
long  elastic  filaments  when  taken  between  the  fingers  or  when 
removed  from  the  urethra  with  an  instrument.  When  placed 
on  a  cover-glass  it  curls  up  into  one  or  more  glutinous  heaps. 
When  one  endeavors  to  spread  these  heaps,  ihey  drag  after  the 
instrument  with  great  tenacity.  They  are  difficult  to  crush  be- 
tween cover-glasses,  and  require  considerable  rubbing  to  spread 
them  with  sufficient  thinness  into  a  "  smear  preparation  "  (Stern- 
berg) for  microscopical  examination.  Moreover,  they  require 
much  more  time  for  the  air-drying  than  is  usually  necessary  for 
flame  fixation  prior  to  staining.  The  microscope  shows  them 
to  contain  many  prostatic  epithelia  and  prostatic  bodies,  in 
addition  to  the  other  elements  that  characterize  the  special  kind 
of  infection. 

DiscHAKGEs  Simulating  Spermatoerhcea. — Guy  on  and  Jamin 
were  the  first  to  point  out  this  symptom  of  chronic  posterior 
gonorrhoea,  which  Guiard '  compares  to  "  little  ejaculations  " 
{petites  ejaculations).  It  is  the  sudden,  intermittent  appearance 
of -a  large  drop  at  the  meatus.  After  the  drop  has  passed  to  the 
linen,  no  more  discharge  can  be  expressed  from  the  urethra, 
unless  by  persistent  "  milking  "  some  normal  secretion  is  pro- 
duced from  the  pendulous  portion.  If  the  patient  is  not  in- 
formed on  the  subject,  he  is  likely  to  consider  these  discharges, 
occurring  at  irregular  intervals,  indications  of  spermatorrhoea 
or  of  urinary  incontinence. 

The  stains  on  the  linen  produced  by  these  discharges  differ 
markedly  from  those  made  by  anterior  gonorrhoea.  The  occa- 
sional sudden  stains  are  fewer  in  number  and  much  larger  than 
those  of  chronic  anterior  gonorrhoea.  Both  kinds  of  spots  may 
appear  together.  Those  ejected  from  the  posterior  urethra  at 
irregular  intervals  generally  have  yellowish- white  centres,  with 
clearer  and  starch-like  peripheries,  when  they  have  dried  on  the 
linen. 

Ordinarily  the  emission  of  these  drops  is  not  accompanied 
by  any  sensation;  their  presence  is  then  not  noted  except  by 
the  moisture  at  the  meatus  or  on  the  shirt,  which  the  patients 
occasionally  feel.     In  some  very  rare  cases  the  emission  of  this 

1  Guiard:   Op.  cit.,  p.  161. 


132  THE   IRRIGATION   TREATMENT   OP   GONORRHCEA. 

drop  is  associated  witli  a  very  brief,  somewhat  pleasurable  sen- 
sation along  tlie  urethra,  suggesting  that  produced  by  the  ejacu- 
lation of  semen. 

Guy  on  emphasizes  that  the  compressor  will  not  yield  to 
pressure  from  within  until  a  sufficient  degree  thereof  is  exercised, 
and  then  urethroprostatic  discharge  is  prevented  from  flowing 
into  the  bladder  by  the  sphincter  vesicae.  The  discharge  so  re- 
tained^  distending  the  posterior  urethra,  evokes  reflex  contrac- 
tions of  the  ejaculatory  muscles.  This  view  is  opposed  by 
many  authors,  but  Guiard's'  observations  fully  support  it. 

While  this  seems  the  most  rational  explanation  of  this 
symptom,  it  cannot,  however,  be  compared  to  the  emptying  of 
the  posterior  urethra  in  ejaculation  of  semen.  During  this  act 
the  posterior  urethra  is  suddenly  filled  with  semen,  and  while 
the  ejaculatory  muscles  are  stimulated  to  spasm  thereby,  the 
compressor  in  this  spasm  ordinarily  yields  intermittently,  in 
concordance  with  their  contractions.  As  opposed  to  the  normal 
ejaculations  the  "little  ejaculations,"  as  Guiard  designates  them, 
appear  to  premise  an  extraordinary  development  of  tonicity  of 
the  sphincter  vesicae,  preventing  the  urethroprostatic  accumula- 
tion from  entering  the  bladder,  which  ordinarily  is  the  point  of 
least  resistance.  This  extraordinary  condition  may  explain 
the  rarity  of  the  symptom  under  discussion. 

The  extrusion  of  these  drops  from  the  posterior  urethra 
certainly  proves  that  a  posterior  gonorrhoea  can  persist  after 
the  anterior  clap  has  subsided.  It^  is  undoubtedly  important 
whenever  they  are  present  that  their  origin  be  ascertained.  In 
this,  aside  of  their  macroscopic  characteristics  mentioned  before, 
the  microscope  will  give  the  final  decision  concerning  their 
source,  whether  they  proceed  from  anterior  gonorrhoea,  pos- 
terior gonorrhoea,  seminal  emissions,  or  the  "  after-dribbling  "  of 
urine. 

Excessive  Moistube.— In  many  cases,  long  after  a  gonor- 
rhoea is  cured,  a  watery  or  slightly  gelatinoid  excess  is  visible 
on  opening  the  meatus,  or  can  be  stripped  or  milked  from  the 
urethra.  If  repeated  microscopical  examinations  of  this  excess 
of  normal  moisture  proves  it  to  contain  only  mucus  and  normal 
epithelium,   and  if  no  other  symptom  of  disease  presents,  it 

1  Guiard:  La  Blennorrhagie  cliez  riiomme,  p.  266,  Rueff,  Paris,  1894. 


CHRONIC   GONORRHCEA.  133 

would  be  exceedingly  unwise  to  subject  the  patient  to  any  local 
treatment,  no  matter  liow  persistently  lie  may  implore  it. 

The  excessive  moisture,  unaccompanied  by  other  manifesta- 
tions of  disease,  may  be  due  to  a  slight  catarrhal  condition  or 
to  constitutional  depression.  The  latter  is  often  caused  by  the 
neurotic  state  that  so  frequently  is  associated  with  and  follows 
gonorrhoea. 

Some  patients  acquire  remarkable  dexterity  in  expressing 
moisture  from  a  perfectly  healthy  urethra  at  all  times.  In  do- 
ing so,  they  keep  the  channel  in  an  irritated  condition,  which 
ceases  as  soon  as  their  thoughts  can  be  diverted  from  continual 
concentration  upon  their  genitalia. 

If  careful  examination  positively  reveals  complete  absence  of 
any  local  ailment,  constitutional  remedies  will  be  required. 
Among  these,  the  mixture  of  tr.  cantharid.  and  iron,  recom- 
mended many  years  ago  by  that  eminent  teacher  Otis,  will  be 
found  effective  in  the  majority  of  cases. 

With  a  view  to  facilitating  the  study  of  excess  of  moisture, 
its  characters  are  here  offered,  preliminary  to  a  better  arrange- 
ment which  doubtless  will  be  made  later. 

In  volume,  the  excess  may  be:  expressible  with  difficulty, 
i.e.,  slight  in  quantity;  easily  expressible,  i.e.,  in  quantity  not 
sufficient  to  form  a  drop,  but  enough  to  be  visible  as  an  excess 
when  the  meatus  is  opened. 

Li  color,  the  excess  may  be:  thin  watery;  thick  watery; 
albuminoid,  like  raw  albumen;  gelatinoid;  grayish;  thin  white 
(like  milk  and  water) ;  thick  white,  like  cream ;  rice-water ;  yel- 
lowish-white;  yellow;  watery,  white  or  yellow  spotted  or 
streaked;  mixtures  of  any  one  or  more  of  the  above. 

I  repeat  that  this  classification  has  no  other  purpose  than 
ease  of  description. 

Excessive  Sexual  Desire. — While  the  prostate  or  seminal 
vesicles  or  both  are  in  a  deteriorated  condition  from  chronic 
gonorrhoea,  or  while  the  urethra  still  suffers  from  the  disease 
or  its  effects,  some  patients  may  be  annoyed  with  what  they 
call  a  "  teasing  "  or  "  nagging  "  impulse  to  indulge  in  sexual  in- 
tercourse. This  may  occur  without  provocation,  or  in  the  pres- 
ence of  women  who  in  no  wise  evoke  sensuality,  as  in  a  public 
vehicle.  Perhaps  it  may  be  well  to  call  this  symptom  "  genesic 
hypersesthesia, "  in  order  to  concisely  describe  it.     An  extreme 


134  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

case  thereof  manifested  the  following  conditions :  While  at  col- 
lege, the  patient,  then  aged  twenty,  contracted  gonorrhoea,  of 
.which  he  was  apparently  cured.  At  twenty-eight  he  married, 
and  became  the  father  of  three  healthy  children  during  five 
years.  His  wife  was  not  infected  by  him.  From  the  time  of 
his  only  gonorrhoea,  he  was  obliged  to  undergo  continual  mental 
struggles  to  master  the  sexual  impulse.  His  business  required 
much  dictation  to  stenographers.  In  selecting  these  employees, 
he  gave  preference  to  those  least  likely  to  suggest  lascivious 
thoughts.  Imagining  that  the  presence  of  any  woman  under 
propitious  surroundings  aggravated  his  condition,  he  eventually 
employed  only  men,  but  soon  found  that  the  sexual  obsession 
was  ever  present,  detracting  materially  from  the  mental  concen- 
tration his  business  demanded.  A  long  vacation  from  his  work, 
and  devotion  to  athletic  exercise,  brought  no  relief.  He  finally 
had  recourse  to  bromides  with  but  temporary  relief,  and  the  re- 
sult that  he  became  a  bromide-habitue.  When  he  was  thirty- 
five  years  old,  he  was  brought  for  consultation.  The  urethra 
showed  a  sliglit,  hard  infiltration  close  behind  the  posterior 
boundary  of  the  fossa;  the  prostate  was  somewhat  enlarged. 
Under  dilatations  of  the  urethra  and  prostatic  massage  for 
about  six  months,  the  conditions  materially  improved.  When 
the  genesic  hypersesthesia  had  subsided  so  far  that  it  but  rarely 
troubled  him,  and  then  only  for  a  few  moments,  he  unfortunately 
was  misled  into  drinking  too  much  champagne  at  a  dinner.  The 
next  day  the  condition  returned  in  an  aggravated  form ;  he  re- 
verted to  large  doses  of  potassium  bromide  and  passed  from 
observation  for  three  months.  He  then  wrote  that  he  could  not 
summon  the  courage  to  discontinue  the  bromide,  which  he  knew 
would  be  required  of  him  if  he  resumed  treatment. 

The  majority  of  cases  do  not,  however,  terminate  in  so  un- 
happy a  manner,  but  yield  to  the  treatment  elsewhere  discussed. 

GONOREHCEAS    THAT    ARE    ChRONIC    FROM    THE    INCEPTION. — In 

some  cases  the  manifestations  of  gonorrhoea  are  so  slight,  and 
their  progress  is  so  insidious,  that  they  appear  to  have  been 
chronic  from  the  very  beginning.  These  Guiard  '  calls  urethrites 
cTironiques  d'emhUe.  The  only  symptom  may  be  so  slight  an 
oozing  from  the  meatus  as  barely  to  attract  attention.     The  ap- 

' Guiard:  Les  Urethrites  chroniques  cliez  I'homme,  Kueff,  Paris,  1898. 


CHRONIC   GONORRHCEA.  135 

parent  insignificance  of  this  discbarge  lias  no  relation  to  the 
relative  number  of  gonococci  it  may  contain,  nor  is  the  pa^tient 
any  the  less  exempt  from  complications  and  sequelae  of  gonor- 
rhoea than  if  it  manifested  itself  in  the  hyperacute  form. 

I  have  not  observed  a  case,  however,  in  which  a  patient's  first 
gonorrhoea  began  with  this  sole  symptom  of  chronicity.  This 
may  explain  the  fact  that  the  gonorrhoeas  apparently  beginning  as 
a  chronic  disease  are  more  tenacious  and  resistant  to  treatment. 

When  the  patient  denies  xjrevious  attacks,  it  may  be  accepted 
that  his  memory  may  be  fallacious  in  this  regard.  Therefore  it 
will  be  well  to  explore  the  urethra  and  adnexa  as  soon  as  pos- 
sible for  residua  of  previous  trouble.  These  must  then  be 
promptly  and  thoroughly  treated,  however  slight  they  may  ap- 
pear to  be. 

Itching  or  tickling  is  one  of  the  most  annoying  and  often 
one  of  the  most  persistent  symptoms  of  chronic  gonorrhoea. 
"WTieu  a  focus  or  several  foci  of  infiammation  or  infiltration  can 
be  discovered  by  the  urethroscope,  the  condition  can  be  relieved 
by  direct  applications  of  silver  nitrate  or  cupric  sulphate.  When 
itching  or  tickling  oscillates  with  varying  intensity  between  spots 
in  the  anterior  and  posterior  urethra,  it  may  be  due :  (1)  To  both 
these  regions  ha\dng  diseased  foci ;  then  temporary  greater  irrita- 
tion in  a  focus  or  foci  in  the  anterior  or  posterior  urethra  may 
obscure  that  of  the  less  disturbed  region;  (2)  involvement  of  the 
seminal  vesicles,  prostate,  or  Cowper's  glands,  from  which  the 
irritation  is  reflected  forward.  In  the  latter  case  urethroscopy 
may  show  a  perfectly  normal  channel;  (3)  fissure  of  the  anus, 
hemorrhoids,  or  rectal  disturbances. 

When  tickling  or  itching  besets  the  posterior  urethra,  it  is 
often  referred  to  the  rectum  or  anus.  Such  cases  are  frequently 
treated  for  a  presumed  rectal  disease  and  even  operated,  natur- 
ally without  result.  On  the  other  hand,  a  fissure  of  the  rectum, 
especially  when  near  the  raphe,  may  cause  urethral  tickling  or 
itching.     Urethral  treatment  must  then  necessarily  be  fruitless. 

It  is  necessary,  therefore,  most  searchingly  to  explore  the 
urethra,  its  adnexa,  the  anus,  and  rectum  when  itching  or  tick- 
ling in  the  urethra  presents.  This  symptom  is  so  harassing 
that  the  local  disturbance  seriously  affects  the  patient ;  if  long 
continued,  it  so  influences  his  general  condition  as  to  unfit  him 
for  his  vocation. 


136  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

When  tlie  cause  is  in  th  euretlira,  it  often  is  so  minute  that 
its  location  is  difficult,  even  by  the  most  careful  urethroscopy. 
Then  if  all  other  causes  can  be  excluded,  dilatations  and  irriga- 
tions fortunately  relieve  the  condition. 

Meatus,  Agglutination  of. — In  some  cases  the  only  mani- 
festation of  chronic  gonorrhoea  is  a  cohesion  of  the  lips  of  the 
meatus.  More  frequently  still  the  lips  are  agglutinated,  requir- 
ing a  little  force  to  separate  them.  When  the  urethral  secretion 
is  a  trifle  greater  than  necessary  to  produce  cohesion  or  aggluti- 
nation, a  little  transparent  pellicle  or  even  a  brownish  crust  may 
form  from  the  secretion  as  it  dries  between  and  upon  the  lips  of 
the  meatus.  This  crust  must  not  be  confounded  with  the  one 
found  upon  the  meatus  of  uncleanly  persons. 

If  the  incrustation  persists,  it  may  make  the  beginning  of 
uri nation,  especially  that  of  the  first  morning  bladder  evacua- 
tion, quite  painful.  The  urinary  stream  tears  the  crust  from 
the  meatus  and  carries  epithelium  with  it. 

Agglutination  and  incrustation  can  be  avoided  in  all  cases 
hj  keeping  the  meatus  covered  with  absorbent  cotton  soaked  in 
bichloride  1 :  10,000  to  1 : 6,000,  or  boric  acid  four  per  cent.  The 
cotton  so  prepared  is  applied  after  each  urination  as  described 
under  the  head  of  Anterior  Irrigations,  in  Chapter  III. 

The  avoidance  of  this  symptom,  however,  by  no  means  im- 
plies its  cure.  A  diagnosis  is  as  necessary  here  as  elsewhere. 
To  ascertain  its  character,  a  small  quantity  of  the  substance 
that  agglutinates  the  meatus  is  taken  with  a  sterilized  (flamed 
and  cooled)  platinum  loop  and  placed  upon  a  cover-glass.  If 
the  substance  is  so  dry  and  hard  that  it  cannot  be  spread  very 
thinly  upon  the  glass,  a  drop  of  distilled  water  added  to  it  will 
quickly  soften  it,  so  that  it  can  be  spread,  dried,  flamed,  stained, 
and  examined  in  the  usual  manner  (see  Chapter  XIV.,  Proofs 
of  Cure  of  Gonorrhoea) . 

The  microscopical  examination  of  a  specimen  so  prepared  will 
show,  in  simple  urethrorrhcea,  epithelium,  mucus,  and  perhaps  an 
occasional  leucocyte;  in  chronic  gonorrhoea,  all  the  above,  de- 
formed or  thinned  epithelia,  or  normal  epithelia,  pus  cells,  gon- 
ococci,  and  perhaps  other  bacteria ;  in  stricture,  when  it  causes 
the  persistence  of  a  gonorrhoea,  all  the  above,  and  epithelia  with 
loss  of  granulation  of  the  epithelial  nuclei  or  epithelia  entirely 
without  nuclei;  in  uncleanliness,   mucus,   epithelium  from  the 


CHRONIC   GONORRHCEA.  13T 

meatus,  pus,  dirt,  and  all  kinds  of  bacteria;  in  consequence  of 
erections,  mucus,  epitlielia  from  several  parts  of  the  urethra, 
and  spermatozoa. 

Morning  Deop.— This  term,  like  its  French  congener  gouUe 
militaire,  is  unfortunately  used  by  many  authors  as  a  synonym 
for  chronic  gonorrhoea.  In  reality  it  is  only  a  symptom,  and  by 
no  means  a  constant  one,  of  chronic  gonorrhoeal  inflammation. 
When,  in  this  disease,  the  discharge  is  continuous,  there  can  be 
no  drop  that  appears  at  the  meatus,  in  the  morning  or  after 
more  or  less  prolonged  intervals  between  urination;  nor  is  a 
morning  drop  ordinarily  found  when  the  only  symptom  of 
chronic  gonorrhoea  is  a  stain  on  the  linen. 

The  persistent  presence  of  this  drop  after  a  night  during 
which  the  patient  has  not  urinated,  by  no  means  implies  that 
the  drop  contains  gonococci.  On  the  other  hand,  the  absence 
of  gonococci  from  the  drop  does  not  prove  that  the  patient  is 
free  from  these  bacteria.  Therefore  the  appearance  of  this 
symptom,  which  may  vary  from  a  clear,  colorless,  to  a  gelati- 
noid,  gray,  mottled,  white  or  yellow  drop,  demands  not  only 
microscopical  examination,  but  also  a  thorough  exploration  of 
the  entire  urethra  and  its  adnexa. 

If  the  patient  with  no  other  symptom  of  disease  than  the 
morning  drop  cannot  come  to  his  physician's  office  before  uri- 
nating, he  should  be  instructed  in  the  proper  manner  of  taking 
the  specimen  on  a  cover-glass.  This  he  then  brings  with  him 
for  examination. 

Numerous  observations  of  cases  in  which  the  morning  drop 
free  from  gonococci  was  the  only  symptom  of  urethral  dis- 
ease, have  led  me  to  the  opinion  that  its  presence  is  due  to  the 
effect  of  gonococci  held  in  some  part  of  the  lower  urinary  ap- 
paratus. The  most  painstaking  and  exhaustive  examination  may 
not  reveal  the  focus  of  inflammation  nor  the  site  where  the 
bacteria  are  residually  held.  To  establish  the  presence  or  ab- 
sence of  gonococci  it  will  be  well,  in  such  a  case,  to  irrigate  the 
urethra  with  silver  nitrate  1 : 1,000  or  1 :  500,  or  mercuric  bichlo- 
ride 1:10,000.  The  discharge  produced  thereby  can  then  be 
examined  for  gonococci.  But  whether  they  are  or  are  not  pres- 
ent, there  will  be  no  use  in  attempting  to  conquer  the  morning 
drop  with  any  of  the  astringent  injections  of  which  so  many  are 
recommended.     Even  in  the  absence  of  any  special  focus  of  dis- 


138  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

ease,  the  case  must  be  treated  by  internal  massage  of  tlie  ure- 
thra, as  directed  when  describing  the  treatment  of  chronic  gon- 
orrhoea bj^  dilatations  and  irrigations. 

Painful  Ejaculations. — In  those  not  due  to  the  ejaculatory 
spasm  drawing  ujDon  nerve  terminals  compressed  in  infiltrations 
of  the  anterior  urethra,  the  pain  may  be  due  to  irritation  of  the 
chronically  inflamed  posterior  urethra,  just  as  urine,  the  normal 
stimulant  to  vesical  contraction,  gives  pain  in  cystitis,  and  as 
light,  the  normal  visual  stimulant,  gives  pain  in  iritis.  These 
painful  ejaculations,  however,  are  by  no  means  essentially  of 
gonorrhoeal  origin.  In  character  they  may  be  lancinating, 
burning,  extending  from  the  meatus  to  the  rectum,  or  radiating 
to  the  testicles  and  lasting  some  time  after  coitus,  which  may 
be  followed  by  scalding  on  urination.  They  are  most  frequent 
in  excesses,  such  as  are  likely  to  be  committed  by  middle-aged 
men  in  sexual  relations  with  very  young  women.  A  most 
aggravated  case  in  which  painful  ejaculation  was  the  exclusive 
symptom  of  chronic  anterior  and  posterior  gonorrhoea,  was  that 
of  an  otherwise  normal  man,  who  screamed  at  the  moment  of 
ejaculation  and  fainted  before  entire  conclusion  of  the  act. 
Usually  the  patients  with  chronic  anterior  urethritis  complain 
of  no  pain  during  ejaculation,  or  only  a  slight  burning.  When 
the  pain  is  sharp,  lancinating,  stabbing,  and  extends  to  the  region 
of  the  anus  or  rectum,  chronic  posterior  urethritis  is  prob- 
ably associated  with  disturbance  of  the  anterior  urethra,  with 
or  without  involvement  of  the  seminal  vesicles  or  prostate,  or 
both. 

Painful  Erections. — These  are  comparatively  rare  when  ac- 
companied by  suflBcient  genesic  impulse  to  overshadow  the  pain. 
But  there  are  cases  in  which  erections  without  sexual  desire  are 
provoked  by  the  presence  of  chronic  localized  inflammation; 
they  then  stretch  the  tense  areas  or  draw  upon  them,  producing 
exquisite  pain,  while  increasing  the  inflammation.  Many  a  man 
has  mere  mechanical  erections  from  an  overfilled  bladder. 
When  the  urethra  harbors  a  chronic  gonorrhea,  the  erections 
are,  as  a  rule,  more  or  less  painful.  They  subside,  however, 
as  soon  as  the  bladder  is  emptied. 

Painful  urination  may  be  frequently  evoked  in  chronic 
gonorrhoea  by  abnormally  irritating  urine,  as  in  oxaluria,  from 
errors  of  diet,  alcohol,  coitus,  or  overexertion.     The  irritation 


CHRONIC   GONOREHCEA.  139 

produced  may  cause  reawakening  of  tlie  dormant  inflammation 
and  with  it  recrudescence  or  increase  of  the  discharge. 

Painful  urination  in  chronic  gonorrhoea  may  also  be  caused 
by  agglutination  or  incrustation  of  the  meatus,  produced  by  a 
small  quantity  of  discharge  drying  upon  or  between  the  lips. 
When  sealing  of  the  meatus  is  very  firm,  the  first  urine  forced 
from  the  bladder  may  distend  the  urethra  most  painfully,  until 
the  incrustation  is  torn  off  by  the  stream.  This  tearing  away 
of  the  crust  is  necessarily  also  painful.  "With  repetition  of  the 
act  it  rends  epithelium  from  the  meatus,  leaving  the  lips 
denuded,  and  increasing  the  painfulness  through  the  heavier 
incrustation  and  greater  denudation  that  follow.  Decided 
ulceration  of  the  entire  meatus  can  result,  if  the  condition  is 
neglected. 

When  alcohol  or  coitus  or  both  have  provoked  the  irritation, 
they  must  naturally  be  forbidden;  when  oxaluria  is  the  cause, 
the  diet  must  be  regulated ;  in  all  cases,  the  patient  should  be 
ordered  to  drink  large  quantities,  three  or  four  quarts,  of  boiled 
water  daily  to  dilute  the  urine. 

Incrustation  of  the  meatus  can  be  entirely  and  easily  pre- 
vented by  causing  the  patient  to  keep  the  meatus  continually 
wet  with  cotton  soaked  in  bichloride  or  boric-acid  solution  as 
directed  where  irrigations  are  described.  When  the  incrustations 
have  formed,  pain  on  urination  can  be  avoided  by  soaking  the 
penis  in  hot  bichloride  or  boric  solution  until  the  crusts  are 
softened  and  can  be  easily  removed. 

Post-Coital  Seminal  Deibbling. — In  some  cases,  in  which 
coitus  is  normal,  it  is  followed  by  more  or  less  copious  dribbling 
of  semen  from  a  but  partially  evacuated  posterior  urethra. 
This  symptom  is  likely  to  occur  as  an  independent  manifesta- 
tion of  urethritis  ex  lihidine.  When  sexual  excesses  take  place 
during  chronic  urethritis,  they  are  the  more  likely  to  provoke 
the  same  condition. 

Pkemature  ejaculations  frequently  overshadow  the  chronic 
gonorrhoea  that  causes  them,  and  often  indeed  are  the  only 
symptom  of  the  disease.  The  local  symptom  may  be  merely 
too  brief  intercourse  before  the  ejaculation.  A  more  marked 
form  is  that  in  which  the  emission  occurs  before  intromission, 
with  subsidence  of  the  erection  as  the  penis  touches  the  external 
female  genitalia.     In  still  more  aggravated  cases,  accidentally 


14:0  THE   IRRIGATION   TREATMENT    OF   GONORRHOEA. 

brushing  against  female  garments  suffices  to  provoke  the  emis- 
sion, while  the  penis  obtains  but  momentary  turgescence,  which 
may  be  so  evanescent  as  to  pass  unobserved. 

In  addition,  these  patients  are  usually  depressed  by  fear  of 
consumjDtion  from  the  frequent  seminal  losses,  the  dread  of  the 
permanent  destruction  of  their  sexual  powers,  and  the  fear  of 
insanity,  which  they  have  cultivated  mainly  from  charlatans' 
advertisements.  The  despair  of  these  patients  is  not  often  over- 
come by  the  physician's  assurances.  They  regain  hope  only 
when  they  observe  the  beginning  of  relief  from  mechanical  treat- 
ment. While  this  is  pursued,  the  closest  attention  must  be  given 
to  the  accessory  treatment  mentioned  in  Chapter  YI. 

Simulated  Anterior  Gongrehcea.- — In  some  cases  the  com- 
pressor allows  the  secretion  behind  it  continually  to  leak  into 
the  anterior  urethra,  giving  the  appearances  of  anterior  ure- 
thritis. The  first  urine  then  coming  from  the  bladder  may 
wash  out  the  entire  urethra  and  thus  be  rendered  turbid;  the 
urine  following,  if  it  detaches  no  secretions,  may  be  clear.  But 
the  last  ounce  of  urine,  forcibly  ejected  by  the  concluding  efforts, 
may  be  rendered  as  turbid  as  the  first,  or  more  so,  by  the  de- 
trusor's compression  of  the  diseased  organs.  If  such  a  patient's 
anterior  urethra  is  gently  irrigated  and  then  examined  with  the 
urethroscope,  it  will  prove  to  be  perfectly  healthy.  Therefore 
when  a  case  of  apparently  chronic  anterior  urethritis  does  not 
yield  to  irrigations,  the  cause  may  be  found  in  the  posterior 
urethra. 

In  an  extreme  case  of  such  a  condition,  the  urethroscope 
found  the  compressor  bulging  forward.  Slight  pressure  upon 
it  with  the  distal  end  of  the  tube  caused  it  to  extrude  enough 
secretion  to  nearly  fill  one  fifth  of  the  tube  (30  F.). 

Stains  on  Linen. — Numerous  patients  present  stains  on  the 
garments  as  the  only  evidence  of  chronic  gonorrhoea.  When  this 
is  the  case,  in  most  instances,  all  endeavors  to  strip  a  discharge 
from  the  urethra  either  fail,  or  bring  to  the  meatus,  but  not  ex- 
pressible from  it,  only  a  slight  excess  of  transparent  moisture. 

Almost  invariably  these  stains  on  the  garments  produce  more 
mental  distress  than  the  discharge  did  when  it  was  copious,  or 
the  morning  drop  when  it  persisted. 

A  patient  whose  garments  become  the  seat  of  such  stains 
uses  every  possible  means  to  impress  the  physician  with  their 


CHRONIC    GONORRHCEA.  141 

importance  as  evidence  of  grave  disease.  One  patient,  a  not  at 
all  ignorant  practitioner,  whom  I  had  treated  for  chronic  gonor- 
rhoea, on  returning  from  a  visit  at  midnight,  found  several  spots 
on  his  shirt  flap  when  he  undressed.  He  awoke  me  an  hour 
later,  and  to  prove  that  he  was  not  cured  produced  the  shirt, 
with  assurance  that  he  intended  to  commit  suicide  in  my  oifice. 
The  color,  shape,  and  appearance  of  the  stains  were  utterly  at 
variance  with  those  that  come  from  urethral  disease.  My  pa- 
tient was  not  convinced,  however,  until  a  microscopical  examina- 
tion, made  at  once,  proved  a  complete  absence  of  bacteria  in  the 
stains,  which,  however,  contained  an  exceedingly  large  number  of 
well-formed  spermatozoa.  He  subsequently  married  the  lady 
with  whom  he  had  spent  the  evening;  her  exceedingly  good 
health  and  frequent  pregnancies  finally  dispelled  the  doctor's 
apprehensions. 

Some  patients  bring  a  formidable  laundry  bundle  to  show 
the  harassing  spots.  One  wore  a  shirt  an  entire  week,  during 
which  he  examined  it  hourly  while  awake ;  whenever  he  found  a 
stain,  he  encircled  it  with  indelible  pencil  and  in  the  circle  marked 
the  date  and  hour  of  its  discovery.  Other  patients  cut  the 
stained  portions  from  the  shirt  flap  and  attach  labels  thereto, 
on  which  they  write  the  same  information.  Impatience  or 
derision  will  not  relieve  the  sufferer's  mental  distress;  reassur- 
ances regarding  eventual  cure  are  equally  fruitless.  The  pa- 
tients will  not  obtain  mental  tranquillity  until  they  cease  to 
find  the  stains. 

"W  hen  the  stains  are  due  to  an  excess  of  urethral  secretion 
they  probably  are  expelled  whenever  the  secretion  has  accumu- 
lated in  sufficient  ciuantity  to  evoke  slight,  unperceived  urethral 
contractions.  The  excess  of  urethral  secretion  may  be  due  to 
slight  post-gonorrhoeal  urethrorrhoea,  to  infiltration  of  the  mu- 
cosa or  of  glands,  or  to  stricture. 

The  gross  clinical  differences  between  the  stains  on  the  gar- 
ments may  be  roughly  tabulated  as  follows : 

Stains    from    tiretliral    Stains  from  drops  of  urine    Seminal  stains : 
discharge:  (as  in  "after-dribbling," 

from  enlarged  prostate,  or 
stricture) : 
Circular  or  ovoid.  Irregularly  shaped ;  diffuse.    Shred-shaped    or    band- 

like. 


142  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Small,  with  sharply  de-    Large,  with  undefined  edges.  Elevated  edges. 

fined  edges. 

Color  same  throughout.    Centre  darker  than  periph-  Varying  thickness  gives 

ery.  deeper  color  in  spots. 

As  Diday  lias  sliown,  the  stains  from  urethral  discharges, 
very  soon  after  they  escape,  assume  another  color  than  that 
which  they  had  when  leaving  the  meatus.  In  the  little  table  .be- 
low I  have  added  my  observations  to  those  of  Diday : 

A  colorless  discharge  produces  a  starch-like      stain. 


An  opaline 

"        "  grayish              " 

A  white 

"        "  yellow                 " 

A  yellow 

"        "  green                   " 

A  green 

"        "  reddish-brown  " 

A  red 

"        "  mottled  dark-brown  stain 

Whatever  the  origin  of  the  stain,  microscopical  examination  is 
necessary,  not  only  for  the  patient's  mental  peace,  but  for  diag- 
nostic purposes  as  well.  The  stained  spot  is  moistened  with  a 
drop  of  distilled  water  and  rubbed  upon  a  cover-glass.  The 
stain  so  transferred  is  air-dried,  flamed,  colored,  and  mounted 
in  the  usual  manner. 

Even  the  most  minute  stains  may  contain  gonococci ;  there- 
fore they  should  not  be  lightly  considered. 

The  treatment  of  the  condition  producing  stains  on  the  linen 
must  be  directed  to  its  cause.  The  stains  themselves,  however, 
can  be  prevented  from  soiling  the  linen  by  keeping  the  glans 
continually  covered  with  cotton,  as  directed  under  anterior 
irrigations. 

Urethboscopio  Findings. — The  conditions  of  the  urethra 
that  sustain  chronic  gonorrhoea  are  sketched  in  the  Outlines  of 
Urethroscopy,  Chapter  XIII. 

The  UEiNE  IN  CHRONIC  GONORRHCEA  is  made  the  subject  of 
exhaustive  discussion  in  very  many  large  scientific  volumes. 
Manifestly,  then,  no  more  can  be  attempted  here  than  very 
rough  outlines  of  the  coarser  manifestations  that  are  accessible 
to  the  beginner  in  practice  and  available  for  rapid  office  work 
in  large  practice.  The  latter,  however,  cannot  be  complete  or 
satisfactory  without  at  least  one  assistant  continually  devoted 
to  microscopical  research. 

The  urine  used  for  examination  should  be  passed  in  the 
physician's  office.     For  convenience,  tubes  should  be  kept  in 


CHRONIC   GONORRHCEA.  143 

quantity  as  mentioned  elsewhere  (page  25).  Previous  to  pass- 
ing tlie  urine,  the  patient's  prepuce,  glans,  and  meatus  should 
be  cleansed  with  absorbent  cotton  soaked  in  boric  acid,  so  that 
the  urine  first  passed  does  not  carry  into  the  tube  the  secretion 
of  balanitis  or  the  diversity  of  foreign  bodies  that  are  some- 
times found  about  the  glans.  Among  these  Professor  Guy  on' 
enumerates  mineral  dust,  coal,  wool,  silk,  linen,  hemp,  cotton 
threads,  bits  of  hair,  feathers,  grains  of  starch,  etc.  Some  of 
these,  by  their  presence,  may  prove  decidedly  misleading  in 
macroscopical  and  microscopical  examination  of  the  urine. 

The  presence  of  some  of  these  objects,  as  visible  to  the  un- 
aided eye  as  are  the  "  floaters  "  mentioned  on  page  67,  become  of 
deep  concern  to  a  patient,  who,  like  the  majority,  observes  that 
at  each  visit  the  physician  carefully  notes  them.  When  they 
do  not  proceed  from  the  urethra,  they  are  easily  eliminated  by 
the  preliminary  cleansing  mentioned  above. 

Malodorous  Urine. — This  is  frequently  the  first  symptom 
which  patients  observe.  It  sometimes  has  a  fishy  odor  in 
chronic  posterior  urethritis  and  in  tumors  of  the  bladder;  an 
excessively  aromatic  odor  after  taking  balsams  {e.g.,  santal  oil); 
a  violet-like  odor— almost  a  perfume— after  taking  turpentine 
preparations,  etc. 

Tui'hid  Urine. — If  the  first  urine  is  turbid  it  is  generally  re- 
garded as  evidence  of  anterior  urethritis.  This,  however,  is 
open  to  error,  as  mentioned  in  connection  with  a  consideration 
of  simulated  anterior  gonorrhoea.  If  washing  out  the  anterior 
urethra  produces  only  clear  wash-water  and  the  first  urine  then 
passed  is  turbid,  disease  of  the  posterior  urethra  is  fairly  well 
established.  If  all  the  urine  passed  is  turbid,  it  may  be  due  to 
an  inflammatory  disease  of  any  part  of  the  urinary  tract,  except 
the  anterior  urethra,  whose  pus  is  generally  washed  away  with 
the  first  150  cgm.  of  urine. 

Donne's  Test. — If  the  turbidity  is  caused  by  pus,  the  addition 
of  a  saturated  solution  of  caustic  potash  and  then  twirling  the 
tube,  will  soon  provoke  that  ropy  separation  which  Donne,  who 
devised  the  test,  called  "snotty."  This  forcible  term  (rotzig) 
does  not  seem  to  have  yet  found  a  more  elegant  and  equally  de- 
scriptive English  equivalent. 

'  Guyon:  Maladies  des  Voies  urinaires,  vol.  i.,  p.  293,  Bailli^re,  Paris, 
1894. 


lU 


THE   IRRIGATION   TREATMENT    OF    GONORRHCEA. 


If  haderuria  causes  tlie  turbiditj^,  caustic  potash  will  not  sepa- 
rate tlie  clear  urine,  as  above  described. 

Pliospliaturia  can  show  the  urine  just  as  turbid  as  in  either 
of  the  preceding  conditions.  A  little  nitric,  hydrochloric,  or 
acetic  acid  will,  especially  after  boiling  the  urine,  clear  it  with 
the  formation  of  bubbles,  causing  it  to  resemble  champagne. 
This  excess  of  phosphates  may  accompany  the  act  of  digestion, 
especially  in  dyspeptics ;  it  may  follow  mental  exertion,  anger, 
fright,  or  apprehension;  it  is  almost  always  present  in  prostatic 
enlargement. 

Perfectly  clear  and  brilliant  urine  by  no  means  proves  absence 
of  disease.  Centrifuging  the  specimen  may  reveal  slight  but 
positive  evidence  that  some  part  of  the  urinary  apparatus  is 
affected. 

Shreds,  fakes,  filaments,  granules  in  the  urine  are  the  symp- 
toms which  bring  patients  to  us  long  after  other  manifestations 
of  disease  have  passed.  Eoughh^  these  substances  found  in 
clear  urine  or  in  urine  not  so  turbid  as  to  conceal  them,  become 
smaller  with  approaching  restoration  to  health.  With  Guyon 
("Maladies  des  Yoies  Urinaries  ")  and  Guiard  ("Les  Urethrites 
Chroniques ") ,  I  deem  the  following  general  classification  of 
these  substances  carried  in  the  urine  the  most  convenient  for 
ordinary  practical  i^urposes : 


Purulent  Filaments.       Muco-Purulent  Filaments. 


Short. 
Multiple. 

Opaque.     Yellowish. 


Fall  rapidly  to  bottom  ; 
dissolve  readily  and 
increase  turbidity. 


Easily  removable  from 
the  urine  with  plati- 
num loop. 


Mucous  Filaments. 
Uniformly  transparent. 


Very  much  longer. 

Less  numerous,  often  have 
ends  rolled  into  a  ball, 
or  are  serpentine. 

Not     homogeneous,     but    No  opaque  spots, 
often  consist  of  thicker 
spots,  held  together  by  a 
more    transparent    sub- 
stance. 

Sink  slowly  and   remain   Light ;  remain  in  the  up- 
coherent    a  long  time.        per  part  or  float  on  sur- 
By    twirling   the    tube       face  of  the  urine, 
they  can  be  made  to  rise 
from  bottom. 

More  difficult  to  "  fish  "  as   Still  more  difficult  to  fish, 
proportion   of    pus    di- 
minishes. 


TREATMENT  OF  CHRONIC  GONORRHCEA. 


145 


Purulent  Filaments.       Muco-Purulent  Filaments. 


Easily  spread  iipou 
cover-glass ;  no  ten- 
dency to  curl. 


Microscopically :  Large 
masses  of  leucocytes, 
few  epithelial  cells, 
no  mucus. 


Tendency  to  roll  into  a 
thick  slippery  heap  or 
serpentine  mass  tipon 
cover-glass. 


Microscopically :  Leuco- 
cytes, often  with  equal 
quantity  of  altered  epi- 
thelial cells,  engiobed  in 
a  substratum  of  mucus. 


Mucous  Filaments. 

Tendency  to  roll  into  a 
clear,  thick  mass  on 
cover -glass,  where  it 
dries  very  slowly  and 
then  is  barely  recog- 
nizable. 

Microscopically  :  Never 
exclusively  mucus  ;  al- 
ways have  some  epithe- 
lial cells,  often  also  a 
few  leucocytes. 


The  omission  of  bacteria  from  the  microscopical  findings  in 
the  above  table  is  intentional.  They  require  sejDarate  extensive 
study.  It  must  not,  however,  be  forgotten  that  the  heaviest, 
coarsest  shreds  may  be  free  from  gonococci,  while  the  finest  of 
short  filaments  may  envelop  an  abundance  of  them. 

The  other  salient  symptoms  of  chronic  gonorrhoea  are  men- 
tioned under  the  Complications  of  Gonorrhoea,  on  page  38. 


IX.  TREATMENT   OF   CHRONIC   GONORRHCEA.' 

Consistent  with  the  character  of  this  little  book,  theoretical 
considerations  will  here  be  entered  into  only  so  far  as  is  neces- 
.sary  to  outline  the  principles  upon  which  treatment  is  based. 
For  the  same  reason,  space  cannot  be  given  to  even  mention  of 
the  many  authors'  names  who  have  worked  and  are  working  so 
efficiently  for  the  clearer  comprehension  of  chronic  gonorrhoea. 
Naturally  no  thought  can  be  devoted  to  those  who  hopelessly, 
from  preconceived  notions  or  from  lack  of  energy  and  persist- 
ence, deem  chronic  gonorrhoea  incurable. 

It  seems  in  place  here  clearly  to  establish  my  position  in 
regard  to  what  is  called  by  very  many  practitioners  the  "  Valen- 
tine method."     The  success  obtained  hj  those  who  followed  my 


'  This  and  the  preceding  chapter  are  somewhat  elaborated,  in  accord  with 
the  results  of  two  years'  increased  study  and  experience,  from  my  article 
on  "  Chronic  Gonorrhoea "  published  in  the  Clinical  Recorder  for  January, 
1898. 

10 


146  THE    IRRIGATION   TREATMENT   OP   GONORRHOEA. 

writings  on  the  subject  makes  this  designation  doubly  flatter- 
ing to  me.  But  those  who  employ  the  term,  even  for  mere  con- 
venience, do  an  injustice  to  others,  principally  Oberlaender  of 
Dresden  and  Janet  of  Paris.  To  Oberlaender  belongs  all  credit 
for  initiating  and  systematizing  the  use  of  dilators ;  to  Janet  is 
due  all  credit  for  methodizing  and  popularizing  irrigations  in 
the  profession.  The  study  of  and  experience  with  both  meth- 
ods led  me  to  simplify  and  combine  them.  Since  early  in  1895 
I  began  to  teach  the  combination,  but  always  emphasized  the 
fact  that  it  is  based  upon  combination  and  a  series  of  modifi- 
cations of  the  methods  advocated  by  the  gentlemen  whose  names 
are  mentioned  above. 

For  practical  purposes  it  is  convenient  to  detail  the  treat- 
ment of  chronic  urethritis,  of  which  less  than  ten  per  cent,  are 
of  other  than  gonorrhoeal  origin,  in  describing  the  instruments 
employed.  The  finer  pathological  considerations  upon  whick 
the  treatment  is  based  can  be  studied  in  the  more  extensive 
works  on  the  subject. 

The  local  treatment  to  be  followed  in  a  given  case  is  pre- 
dicated upon  the  conditions  that  present. 

1.  If  the  affection  is  superficial  it  will  yield  to  irrigations, 
as  described  on  page  18.  Ordinarily  one  series,  requiring 
eight  days  of  such  irrigations,  will  suffice  to  cure  the  case.  Oc- 
casion ally  a  repetition  of  this  series  of  irrigations  will  be  re- 
quired. 

2.  If  the  urethritis  causes  structural  changes  of  the  mucosa, 
or  involves  the  deeper  tissues,  or  has  invaded  the  ducts  of  the 
crypts,  glands  and  follicles  of  the  channel,  dilatations  will  be 
required  for  their. own  effect.  The  manner  in  which  these  dila- 
tations are  performed  is  described  on  page  160  et  seq. 

3.  If  the  urethritis  depends  upon  invasion  of  the  crypts, 
glands  and  follicles,  these  will  have  to  be  slit,  curetted,  or  de- 
stroyed by  electrolysis  before  the  materies  morbida  they  con- 
tain can  be  liberated.  Similar  treatment  is  required  when 
diverticula  or  false  passages  complicate  the  case. 

4.  If  neoplasms  are  the  cause  of  the  urethritis,  they  must 
be  removed  in  accord  with  modern  surgical  principles. 

5.  If  the  urethral  adnexa  are  involved,  they  must  be  treated 
as  outlined  under  complications  (Chapter  VII.). 

The  urethroscopist  has  a  decided  advantage  over  the  phy- 


TREATMENT   OF   CHRONIC   GONORRHCEA  147 

sician  who  does  not  use  tliis  instrument,  which  exposes  to  sight 
the  urethral  disturba,nce.  The  patient  has  still  greater  advan- 
tage, for  when  the  urethroscope  is  used  treatment  can  at  once 
be  directed  to  the  conditions  found. 

Until  the  physician  has  familiarized  himself  with  the  ure- 
thral appearances,  his  methods  will  necessarily  be  tentative. 
The  diagnosis,  then,  being  by  a  slow  process  of  exclusion,  is 
obtained  by  successive  failures  in  treatment. 

Superficial  Invasions  of  the  llucosa.- — The  quantity,  color,  and 
consistence  of  the  discharge,  the  presence  or  absence  of  specific 
•  bacteria,  do  not  indicate  the  depth  of  the  structural  invasion. 
The  epithelia  contained  in  the  discharge  and  in  the  urine,  how- 
ever, are  valuable  guides  thereto ;  but  their  differentiation  pre- 
mises a  degree  of  special  microscopical  training  whose  acquisition 
cannot  be  too  highly  recommended.  The  microscopical  findings, 
it  must  be  remembered,  are  subject  to  great  variability,  often 
due  to  extraneous  circumstances.  Recognizing  this,  the  most 
experienced  microscopist  will  not  decide  on  the  absence  of  gono- 
cocci,  in  a  given  case,  before  making  at  least  ten  examinations 
of  specimens,  each  taken  at  one  or  more  days'  interval. 

The  presence  of  many  gonococci  in  a  case  of  chronic  ure- 
thritis does  not  necessarily  convey  that  the  disease  has  made 
deep  ingression,  or  that  serious  structural  changes  exist,  or 
that  the  adnexa  are  involved.  Obversely,  a  specimen  containing 
but  few  gonococci  does  not  bear  evidence  that  the  case  is  a  light 
one,  or  that  it  will  respond  readily  to  treatment. 

Ordinarily  a  patient,  the  superfices  of  whose  urethra  are  the 
site  of  the  disease,  may  be  expected  to  recover  promptly  after 
one,  or  at  most  two  series  of  irrigations.  These  failing,  the 
physician  who  has  not  assured  himself  of  the  condition  by 
means  of  the  urethroscope  must  conclude  that  deeper  tissues 
are  invaded,  a  fact  which  he  could  have  established  weeks  be- 
fore, had  he  examined  the  urethra.  He  will  then  proceed,  as  he 
would  have  done  at  once,  to  dilatations. 

Structural  Changes  of  the  Blucous  Superfices,  the  Deeper  Tis- 
sues, or  the  Gland  Ducts.— DeBpiiQ  the  marked  pathological  differ- 
ences between  the  conditions  here  placed  together,  their  grouping 
is  warranted  by  the  fact  that  their  efficient  treatment  is  almost 
identical.  As  long  as  men  have  written  on  urethral  diseases, 
drugs  of  all  kinds   have  been  proposed   for  the  treatment  of 


148  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

these  conditions  and  tlie  others  that  maintain  urethral  dis- 
charges. The  absurdity  of  expecting  remedies  injected  into  the 
urethra  to  cure  changes  in  its  structure  does  not  seem  to  be  yet 
quite  evident  to  all.  Indeed,  even  to-day  a  medical  journal 
rarely  appears  without  at  least  mention  of  one  drug  or  formula 
advocated  to  cure  chronic  gonorrhoea.  Occasionallj^  in  con- 
sequence of  vigorous  advertising  by  the  manufacturer,  a  drug 
acquires  considerable  vogue  for  a  while.  Soon  it  sinks  into 
merited  oblivion,  to  which  it  is  relegated  even  by  those  who 
strenuously  urged  it. 

Mechanical  methods,  too,  have  their  advocates,  and  have  had 
them  for  a  long  time.  Many  proved  utopian,  but  most  of  these 
have  the  merit  of  leading  to  the  use  of  dilators,  which  for  fully 
fifteen  years  have  proven  effective  in  the  hands  of  those  who 
conscientiously  employ  them. 

Regarding  the  dilatation  treatment  of  chronic  urethral  dis- 
eases, Oberlaender'  says:  "As  to  the  principle  itself,  upon 
which  instrumental  treatment  is  based,  all  agree  that  the  pur- 
pose thereof  is  to  stretch  or  burst  infiltrations,  be  they  hard  or 
soft,  by  means  of  superficial  or  subcutaneous  injury  thereof." 
He  further  says  that  the  end  in  view  can  hardly  be  attained 
with  sounds,  owing  to  the  very  frequent  disproportion  between 
the  calibre  of  the  meatus  and  the  urethra.  Moreover,  the  in- 
sertion of  sounds  sufficiently  large  to  produce  an  effect  upon 
the  diseased  areas  is  often  painful ;  indeed  even  after  the  widest 
possible  meatotomy  it  is  frequently  infeasible. 

Some  of  the  above  facts  which  Oberlaender  mentions,  led 
him  to  work  for  a  number  of  years  with  insufficient  spring  in- 
struments. Accidentally  an  Otis  divulsor  then  fell  into  his 
hands ;  in  the  course  of  time  Oberlaender  constructed  a  number 
of  modifications  thereof,  suited  for  every  zone  of  the  urethra. 

While  a  sense  of  justice  compels  unsparing  credit  to  Ober- 
laender for  his  modifications  of  the  dilators  and  his  systema- 
tization  of  the  treatment  of  chronic  urethritis,  and  while  he 
must  be  unqualifiedly  acknowledged  as  the  founder  of  the 
modern  and  rational  treatment  of  this  most  frequent  and  erst- 
while obstinate  disease,  an  honest  difference  of  opinion  regard- 

'  Oberlaender  :  "Die  chronischen  Erkrankangen  der  mannliclien  Harn- 
Tohre."  Klinisches  Handbuch  der  Haru-  und  Sexualorgane,  vol.  iii.,  Vogel, 
Leipzig,  1894. 


TREATMENT  OF  CHRONIC  GONORRHOEA.        149 

ing  the  principle  on  which  it  is  based  may  be  allowed.  Experi- 
ence and  careful  observation  do  not  seem  to  make  it  necessary, 
nor  is  it  at  all  obvious  from  his  practice  and  writings,  that  the 
effect  of  dilatations  is  due  to  the  stretchings  or  bursting  of  infil- 
trations. Their  effect,  on  the  contrary,  seems  due  to  the  dynamic 
influence  which  Guyon  so  graphically  attributes  to  sounds  that 
lie  loosely  in  a  strictured  or  infiltrated  urethra.  It  is  within 
the  experience  of  every  practitioner  that  a  urethra  which 
easily  admits  a  No.  1,  2  or  3  F.  sound  will,  if  the  sound  is 
left  in  situ,  allow  a  No.  5,  6,  or  larger  calibre  to  pass  readily  in 
twenty-four  hours.  After  the  same  interval  the  patient  finds 
that  he  emits  a  larger  urinary  stream,  with  less  need  of  aid  from 
abdominal  pressure  than  before.  The  presence  of  the  small 
sound  lying  loosely  in  the  stricture  therefore  must  induce  a 
species  of  "retrograde  metamorphosis,"  if  this  term  may  be  so 
applied  to  the  changes  in  the  infiltration  itself,  that  permit  a 
part  of  it  to  be  carried  off.  Inadequate  and  elementary  as  this 
explanation  is,  it  is  offered  as  an  introductory  to  the  study  of 
the  "dynamic  influence  "  (Guyon)  of  instruments  in  the  urethra 
and  to  the  effect  of  dilators  in  chronic  urethritis,  as  established 
by  Oberlaender.  His  terms  to  "  stretch  and  burst  infiltrates  " 
are  thereby  materially  modified,  as  are  whatever  of  violence  or 
painfulness  they  may  convey.  Indeed,  he  does  the  same  thing 
in  urging  gentleness  in  instrumentation  and  very  gradual  in- 
crease in  dilatations. 

The  gentleness  necessary  in  dilatations  is  practically  em- 
phasized when  a  very  narrow  canal  or  urethral  hypersesthesia 
prohibits  the  introduction  of  a  dilator.  Either  condition  must 
then  be  overcome  by  the  preliminary  use  of  flexible  bougies, 
always  selecting  one  that  will  readily  glide  through  the  urethra 
without  producing  pain.  The  limit  of  usefulness  of  these 
bougies  is  reached,  usually  at  18  or  20  F.  when  an  Oberlaender 
dilator  can  be  readily  and  painlessly  inserted. 

The  preparatory  treatment  of  the  urethra  by  flexible  bougies 
is  subject  to  the  same  rules  that  govern  the  use  of  dilators.  The 
practitioner  will  do  well,  however,  to  recall  the  precautions 
necessary  for  aseptic  and  thorough,  albeit  painless  work  with 
these  instruments. 

Previous  to  the  introduction  of  any  instrument,  every  effort 
should  be  made  to  prevent  carrying  with  it  infection  into  and 


150  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

from  one  part  of  tlie  urethra  to  another.  Naturally,  in  the  light 
of  our  present  knowledge,  no  pretence  can  be  made  to  rendering 
the  urethra  aseptic;  yet  every  precaution  must  be  employed 
to  reduce  the  danger  of  infection.  Cleansing,  preliminary  to 
urethral  instrumentation,  is  most  easily  performed  by  irrigation 
of  the  channel  as  described  on  pages  12  and  18.  When,  as  at  a 
distance  from  the  office,  no  irrigator  is  at  hand,  urethral  wash- 
ings may  be  performed  with  large  hand  syringes,  such  as  are 
known  as  the  Guy  on  or  Janet  syringes. 

Dilators  are  inserted  into  the  urethra  in  the  same  manner  as 
are  most  other  instruments.  The  penis,  held  erect  in  the  left 
hand,  causes  the  pendulous  portion  of  the  urethra  to  form  an  ap- 
proximate right  angle  to  the  mesian  line  of  the  body.  The  fossa 
navicularis  (scaphoid  fossa)  forms  an  obtuse  angle  with  the  ure- 
thra. Therefore  an  instrument  to  easily  enter  the  ca,nal  should 
be  guided  first  through  the  fossa  in  the  direction  of  its  lumen, 
then  turned  upward,  to  pass  into  the  urethra.  It  may  meet  an 
excessively  developed  lacuna  magna,  which  may  receive  the 
point  of  the  instrument,  and,  if  violence  is  employed,  expose  the 
patient  to  the  dangers  of  urethral  laceration.  This  danger  is 
the  greater  the  smaller  the  instrument  employed.  The  lacuna 
magna  is  situated  in  the  upper  urethral  wall ;  therefore,  to  avoid 
it,  the  instrument  should  here  be  guided  along  the  floor  of  the 
canal.  All  works  on  surgery  that  have  been  searched  on  the 
matter  of  urethral  instrumentation,  except  a  paper  by  Murcell,^ 
urge  that  the  passage  of  an  instrument  throughout  the  anterior 
urethra  must  be  along  its  roof,  where  it  will  meet  with  few  or  no 
rugosities.  In  theory  this  course  seems  correct.  But  the  sur- 
geon's concentration  being  directed  to  the  roof  of  the  urethra, 
he  can  allow  the  rugae  of  its  floor  to  escape  the  attention  of  the 
instrument  which  at  the  time  is  prolonging  his  tactile  sense. 
Minute  study  and  extended  experience  will  make  plain  the  great- 
er safety  and  ease  of  adopting  a  diametrically  opposite  course. 
The  smallest  damage  that  can  then  be  done  is  an  interference 
with  the  easy  passage  of  the  instrument.  This  can  be  at  once 
remedied,  and  it  will  be  almost  automatically  done,  if  the  tip  of 
the  instrument  is  made  to  hug  the  floor  of  the  urethra.     Then 


*H.  Temple  Murcell :  "Some  Points  in  the  Diagnosis  and  Treatment  of 
Urethral  Stricture."    Treatment,  July  27th,  1899. 


TREATMENT  OF  CHRONIC  GONORRHCEA.        151 

the  most  minute  impediment  to  its  onward  course  causes  the 
surgeon  to  withdraw  the  instrument  ever  so  slightly  and  point 
its  tip  toward  the  roof  enough  to  easily  override  the  obstacle. 
In  this  manner  urethrospasm,  which  would  interfere  with  the 
work,  is  avoided,  as  is  laceration  of  the  urethra. 

We  are  also  urged  to  avoid  the  floor  of  the  bulbous  portion 
and  the  region  beyond,  as  it  is  the  urethra's  least  supported 
part,  and  therefore  the  one  most  exposed  to  injury.  Again,  in 
this  regard  a  difference  in  opinion  and  practice  from  that  of  our 
justly  most  honored  colleagues  in  the  specialty,  may  be  per- 
mitted. Greater  safety  to  the  region  lies  certainly  in  seeking 
it,  with  that  exquisite  gentleness  which  must  characterize  all 
genito-urinary  work.  Thus,  if  it  be  kept  in  mind  that  the  sinus 
of  the  bulb  may  be  quite  a  pouch  and  this  obstacle  to  the  in- 
strument's progress  be  carefully  sought,  a  slight  withdrawal  of 
the  instrument  and  raising  its  point  to  override  the  opening  of 
the  pouch  are  more  likely  to  lead  to  success  than  timorous 
avoidance  of  the  region.  AVhen  the  compressor  is  passed,  how- 
ever, the  point  of  the  instrument  must  hug  the  roof  of  the  pos- 
terior urethra,  which  here  is  the  channel's  true  "surgical  wall," 
to  avoid  contact  with  the  sensitive  caput  gallinaginis  and  the 
mouths  of  the  ducts  that  open  in  this  region. 

All  dilators,  except  those  provided  with  an  irrigating  device, 
are  clothed  with  a  rubber  cover  before  their  insertion  into  the 
urethra.  Excellent  covers  for  all  the  dilators  are  made  accord- 
ing to  my  directions,  by  the  Miller  Eubber  Manufacturing 
Company,  of  Akron,  Ohio.  These  covers  differ  from  those  of 
European  manufacture  essentially  in  being  about  one  millimetre 
greater  in  calibre  and  in  being  finished  with  a  smooth,  instead 
of  a  ribbed,  surface.  The  greater  calibre  permits  their  easier 
adjustment  to  and  removal  from  the  dilators;  their  smooth  sur- 
face makes  the  insertion  of  a  dilator  as  painless  as  the  correct 
introduction  of  a  solid  instrument  with  a  highly  finished, 
nickelled  surface. 

Clothing  dilators  with  these  new  covers  is  performed  by 
grasping  the  mouth  of  the  cover  with  the  left  fingers  and  drawing 
the  cover  over  the  dilator.  This  can  always  be  done  with  ease 
if  the  cover  is  thoroughly  dry.  No  attempt  should  be  made  to 
apply  a  cover  if  it  retains  the  slightest  moisture  from  steriliza- 
tion. 


152  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Although  the  element  of  expense  has  no  weight  in  aseptic 
considerations,  it  is  well  to  remember  that  the  price  at  which 
these  covers  are  furnished  makes  it  quite  an  economy  to  throw 
them  away  after  one  use,  in  preference  to  devoting  the  time, 
labor,  and  cost  of  materials  to  their  resterilization. 

But,  unless  the  covers  are  bought  in  a  sterilized  condition 
and  enclosed  in  glass  tubes,  they  should  be  sterilized  before 
each  use.  To  this  end  they  must  be  scrubbed  in  boiling  water 
with  soap,  each  one  then  wrapped  in  a  sterilized  gauze  napkin 
and  boiled  seven  minutes  in  a  one-per-cent.  carbolic-acid  solu- 
tion. They  may  then  be  left  to  dry  for  use.  Easier  still  is  dry 
sterilization  in  formalin  fumes,  after  scrubbing  with  soap  and 
hot  water.  After  sterilization  and  drying,  if  the  wet  method  is 
employed,  the  covers  must  be  placed  in  a  long  shallow  glass 
or  porcelain  tray,  closed  with  a  tight-fitting  lid  of  the  same  ma- 
terial. Beneath  and  upon  each  layer  of  sterilized  covers  a 
liberal  quantity  of  finely  powdered,  sterilized  talcum  is  dusted. 
If  the  gauze  napkin  is  left  open  at  the  orifice  of  the  cover, 
enough  talcum  will  enter  to  keep  its  inner  surface  dry  and  facili- 
tate its  gliding  upon  and  from  the  dilator. 

After  a  dilator  is  clothed  with  its  cover,  the  instrument  is 
struck  several  times  upon  the  gauze  napkin  that  enveloped  it. 
The  napkin  is  folded  or  crumpled  in  the  left  hand  to  receive  these 
blows  by  means  of  which  any  talcum  adhering  to  the  cover's 
outer  surface  is  removed. 

After  clothing  the  dilator  smoothly  and  assuring  himself 
that  folds  are  nowhere  formed,  the  operator  violently  turns  the 
screw  at  its  handle,  as  if  to  forcibly  burst  the  cover.  When  the 
branches  of  the  dilator  are  so  expanded  to  their  fullest  extent, 
every  part  of  the  cover  is  carefully  examined  for  minute  orifices. 
In  new,  well-made  covers  these  will  not  be  found.  It  is  mani- 
festly better  that,  if  a  cover  contains  holes  or  can  be  burst  by 
the  dilator,  this  be  learned  before  it  enters  the  urethra.  A  de- 
fective cover  inserted  would  permit  urethral  secretions  to  enter 
the  delicate  joints  of  the  dilator,  and,  what  is  far  more  impor- 
tant, endanger  the  urethral  mucosa  to  being  grasped  and  injured 
by  the  dilator's  branches. 

When  the  above  tests  of  the  cover's  good  condition  are  com- 
plete, it  is  lubricated  from  its  point  to  half  an  inch  along  its 
shaft.     The  material  experience  has  shown  most  useful  for  this 


TREATMENT  OF  CHRONIC  GONORRHCEA. 


153 


purpose  is  lubrichondrin,  made  according  to  Professor  Bangs' 
direction.  It  is  composed  of  the  gelatinous  substance  of  clion- 
drus  crispus  (Irish  moss)  to  which  eucalyptus  oil  1:1,000  and 
formaldehyde  1:1,500  are  added.  Lubrichondrin  is  sold  in 
collapsible  tubes  and  in  glass-stoppered  salt  mouths.  The 
former  can  be  resterilized  by  boiling  the  closed  tube  in  water. 
In  using  a  tube  its  bottom  is  compressed  to  force  out  the  con- 


FiG.  40.— Lubricating  the  Meatus. 

tents,  of  which  the  necessary  quantity  can  be  placed  directly 
upon  the  dilator  cover.  When  the  bottles  are  used,  about  a 
sixth  of  a  drachm  of  lubrichondrin  is  poured  into  a  sterilized 
Petri  dish,  whence  it  can  be  readily  taken  upon  the  point  of  the 
dilator. 

Unless  the  physician  is  ambidextrous,  it  will  be  well  for  him 
to  stand  at  the  right  side  of  the  table  upon  which  the  patient 
lies.  The  meatus  being  cleansed  with  cotton  and  bichloride, 
and  the  urethra  washed  as  directed  in  this  chapter,  the  penis  is 
held  as  before  suggested,  and  a  part  of  the  lubricant  smeared 
upon  and  between  the  opened  lips  of  the  meatus  by  drawing 
one  side  of  the  covered  dilator  over  them.     Then  the  dilator 


154  THE   IRRIGATION  TREATMENT   OF   GONORRHCEA. 

may  be  inserted.  In  doing  tliis,  no  force  whatever  should  be 
employed.  When  a  dilator  for  the  anterior  urethra  is  used,  it 
is  best  held  as  if  it  were  a  pen  grasped  for  writing.  "While  fol- 
lowing the  suggestions  before  made,  until  the  posterior  bound- 
ary of  the  fossa  navicularis  is  passed,  the  right  hand  exercises 


Fig.  41.— Oberlaender  Anterior  Dilator. 

a  species  of  restraining  force  to  prevent  the  weight  of  the  in- 
strument violently  plunging  it  into  the  urethra. 

The  selection  of  a  dilator  is  necessarily  predicated  upon  the 
location  of  the  disease  and  the  calibre  of  the  urethra.  If  the 
anterior  urethra  alone  requires  treatment  and  the  urethral  calibre 
is  still  small,  Oberlaender's  anterior  dilator  is  used.  This  in- 
strument has  a  slight  curve  near  its  tip,  to  readily  accommodate 
it  to  the  normal  curve  of  the  anterior  urethra.  The  tij)  is  rather 
small,  permitting  its  insinuation  through  a  stricture  so  narrow 
that  it  will  let  no  instrument  beyond  10  F.  pass.  The  smallness 
of  the  tip  should  be  well  kept  in  mind  when  using  this  instru- 
ment ;  if  the  greatest  of  gentleness  is  not  employed,  it  may  en- 
gage in  a  mucous  fold,  a  wide  open  duct  mouth,  or  a  previously 
made  false  passage.  The  instrument  will  then  not  proceed. 
The  slightest  force  employed  is  likely  to  produce  serious  ure- 
thral laceration.  When  an  obstacle  of  any  kind  impedes  the 
easy  progress  of  the  dilator,  the  instrument  must  be  immedi- 
ately withdrawn  and  a  successive  systematic  series  of  other 
directions  given  its  point.  With  well-developed  tactile  sense, 
however,  the  surgeon  is  enabled  by  gently  touching  all  parts  of 
the  obstacle  to  form  a  clear  mental  picture  of  its  character. 
When  the  point  of  the  instrument  has  found  the  correct  urethral 
lumen,  it  will  easily,  smoothly  glide  to  its  destination,  unless 
again  impeded  by  further  obstacles.  These  then  will  have  to 
be  overcome  in  the  same  manner  as  the  first. 

Greater  safety  from  injury  to  the  urethra  is  obtained  by  in- 
serting the  Oberlaender  anterior  dilator  by  a  technique  similar 
to  that  employed  in  introducing  dilators  for  the  posterior  ure- 
thra, which  will  be  detailed  in  discussing  these  instruments. 


TREATMENT  OF  CHRONIC  GONORRHCEA. 


165 


The  curve  of  the  Oberlaender  anterior  dilator  being  the  nearest 
approach  to  that  of  the  anterior  urethra  therefore  exercises  the 
most  direct  pressure  upon  its  roof  and  floor  without  distorting 
the  canaL  This  consideration  of  the  urethral  curve  is  unneces- 
sary when  the  channel  is  or  has  become  sufficiently  capacious 
to  easily  admit  the  Kollmann  anterior  dilator,  which  is  described 
below. 

The  steps  of  inserting  the  Oberlaender  anterior  dilator  are 
as  follows : 

1.  The  patient  lies  on  a  firm  table  with  his  legs  extended 
and  a  sterilized  towel  placed  upon  his  abdomen  covering  the 
pubis,  another  over  his  testicles  and  thighs.  The  penis  rests 
upon  the  latter  towel. 

2.  After  the  penis  has  been  cleaned,  the  glans  is  taken  be- 
tween the  left  thumb  and  index  finger. 

3.  The  penis  is  gently  placed  in  the  direction  of  the  right 
thigh,  in  a  line  continuing  the  left  Poupart's  ligament. 

4.  The  clothed  Oberlaender  anterior  dilator  is  then  taken  as 


Fig.  43.— Maimer  of  Holding  DUator. 


before  described,  like  a  pen,  with  the  face  of  the  dial  resting 
upon  the  interspace  between  the  right  thumb  and  index  finger. 

5.  The  tip  of  the  instrument  is  inserted  into  the  meatus. 

6.  After  overcoming  the  angle  at  which  the  fossa  stands  to 
the  urethra,  the  penis  is  drawn  over  the  dilator,  as  a  glove  is 
drawn  over  a  finger,  but  far  more  gently.  The  tip  of  the  instru- 
ment is  so  guided  along  the  floor  of  the  urethra  until  the  bulbous 


156  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

portion  is  reached.     The  surgeon  then  experiences  a  sensation 
of  reduced  resistance  at  the  instrument's  point. 

7.  Without  increasing  the  pressure,  but  keeping  the  tip  im- 
mobile, the  surgeon  carries  the  penis  containing  the  dilator  in 
about  a  three-quarter  circle  in  the  same  plane,  around  and  be- 
yond the  patient's  left  side,  until  the  dial  of  the  dilator  faces 
the  linea  alba  at  its  commencement  above  the  pubis. 

8.  Keeping  the  tip  within  the  bulbous  portion,  the  dilator  is 
now  gently  tilted  from  the  floor  to  the  roof  of  this  region,  and 


Fig.  43.— Patient  In  Position  During  Dilatation. 


the  penis  with  the  dilator  raised  until  it  stands  at  right  angles 
to  the  body. 

9.  The  patient's  elbow,  either  right  or  left,  is  rested  against 
his  side  to  steady  his  arm.  He  is  then  asked  to  grasp  the 
dilator,  where  its  cover  projects  from  the  meatus,  and  hold  it 
in  this  position. 

10.  If  the  dilatation  is  to  be  in  prolonged  session  it  will 
materially  contribute  to  the  patient's  comfort  to  raise  the  back 
of  the  table  to  about  forty-five  degrees  and  elevate  its  feet.  I 
find  the  tables  made  by  the  Allison  Compan}^  most  convenient 
for  the  purpose,  as  well  as  for  all  other  genito-urinary  work 
done  in  the  office. 


TREATMEISiT   OF    CHRONIC   GOXORRHCEA. 


157 


Furtlier  manipulations  with  tlie  Oberlaencler  anterior  dilator 
do  not  differ  essentially  from  those  to  be  described  in  discuss- 
ing tlie  other  dilators. 

KoUmann's^four-branched  dilator  for  the  anterior  urethra  is 
intended  for  use  when  the  urethra's  capacity 
is,  or  when  previous  dilatations  have  brought 
it  to  21  r.  The  technique  of  its  employ- 
ment is  the  simplest  of  all 
dilators.  After  the  dilator 
is  clothed  with  its  cover 
and  lubricated,  the  penis 
is  held  in  erect  position 
by  the  left  hand.  The  di- 
lator is  slowly  inserted, 
observing  the  general  rules 
before  mentioned.  The 
dial  may  be  placed  in  any 
direction,  as  the  instru- 
ment when  closed  is  per- 
fectly round.  The  one  of 
choice  will  naturally  be 
that  in  which  the  light 
strikes  the  dial,  so  that 
the  figures  thereon  can  be 
easily  read. 

Oberlaender's  Benique- 
curve    dilator   exercises 
pressure   only  within  the 
Mi^^  posterior    urethra.      The 

technique  of  its   insertion 
is  as  follows : 

1.  Follow  all  the  steps, 
from  1  to  8  inclusive,  laid 
down  for  the  introduction  of  the  Oberlaender 
anterior  dilator. 

2.  When  the  tip  of  the  instrument  has  been  raised  to  the  roof 
of  the  bulbous  portion,  guide  it  gently  through  the  compressor, 
while  letting  the  handle  sink  between  the  patient's  thighs. 
In  this  motion,  contact  of  the  tip  with  the  delicate  and  sensitive 
structures  at  the  floor  of  the  posterior  urethra  is  avoided. 


158 


THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 


Undeniably  brilliant  results  are  obtained  in  affections  of  the 
posterior  urethra  from  the  use  of  tliis  dilator,  without  disturbing 
the  anterior  urethra.  In  the  premature  ejaculations  due  to 
irritability  of  the  posterior  urethra  from 
masturbator's  chronic  hypersemia,  it  often 
exercises  a  decided  salutary  effect.  But  it  is 
not  an  instrument  that  can  be  recommended 
to  any  save  those  whom  large  experience 
has  made  familiar  with  intra-urethral  work. 

1  The  very  great  Benique  curve,  alarming 
^  as  it  may  appear  to  the  patient,  allows  the 
g  instrument  to  lie  very  easily  in  the  urethra, 
i  without  making  any  traction  whatever  upon 
^  its  normal  bend.  But  this  very  curve  and. 
^  its  small  tip  make  its  introduction  safe  only 
%  in  trained  hands. 
a  Kollmann's  four-branched  dilator  for  the 

2  bulb  and  posterior  urethra  is  a  much  safer 
I    instrument  to  use.     It  cannot,  however,   be 

3  employed  through  an  anterior  urethra  w^hose 
§  capacity  is  less  than  21  F.  Its  large  tip  ex- 
I  eludes  the  danger  of  injury,  unless  violence 
^  is  employed.  Its  Guy  on  curve,  about  one- 
§  half  of  that  of  the  Benique,  does  not  exer- 
g    cise  any  appreciable  traction  upon  the  ure- 

1  thra,  while  its  great  weight  adds  to  the 
§  ease  of  its  introduction.  The  technique 
o    thereof  is  the  same  as  that  laid  down  for 

2  the  Oberlaender  posterior  dilator. 
Oberlaender's  curved  dilator  for  the  pos- 
terior and  anterior  urethra  is  used  when 
both  these  regions  require  dilatation.  The 
technique  of  its  introduction  is  identical 
with  that  directed  for  the  Oberlaender  Be- 
nique-curve  dilator.  The  angle  at  which  it 
is   depressed   between    the    thighs   governs 

the  dilatation  that  is  to  be  done  within  the  bulbous  portion  or 
beyond.  Dilatation  of  the  anterior  urethra  is  accomj)lished  at 
the  same  time. 

Kollmann's    four-branched     Guyon-curve     antero-posterior 


TREATMENT  OF  CHRONIC  GONORRHCEA. 


159 


dilator  is  applicable  wlien  botli  uretliras  require  treatment  and 
permit  tiie  passage  of  an  instrument  over  21  F.  The  technique 
of  its  insertion  does  not  differ  from  that  before  described  for  the 
instruments  intended  for  these  regions.  * 


Kollmann,  whose  ingeniousness  seems  to  have  no  limit,  also 
devised  irrigating  dilators  (Fig.  49  and  50).  They  are  used 
without  rubber  covers.  Surgical  cleanliness  of  these  irrigating 
dilators  is  obtained,  according  to  the  author's  directions,  as 
follows : 


160  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

1.  Place  the  dilator  into  absolute  alcohol  for  an  hour  before 
use ;  then  pass  it  over  a  flame,  burning  off  all  the  alcohol  that 
adheres  to  it. 

2.  "When  the  dilator  has  grown  cool,  stand  it  upright  in  a  tall 
vessel  and  force  boric  acid  through  its  canals. 

3.  Previous  to  inserting  it  into  the  urethra,  pass  a  sound 
and  leave  it  there  for  a  few  moments. 

4.  Anoint  the  dilator  freely  with  glycerin  before  inserting  it. 

5.  After  use,  scrub  the  dilator  vigorously  with  soap  and 
water.  After  having  dried  it,  cleanse  with  benzin  applied  by 
means  of  a  tooth-brush,  and  then  with  absolute  alcohol. 

These  dilators,  when  inserted,  have  a  short  rubber  tube  at- 
tached to  one  of  their  nipples  and  a  long  one  to  the  other.  The 
short  tube  is  connected  to  a  syringe  by  means  of  which  the 
irrigation  fluid  is  forced  through  the  dilator  into  the  urethra  and 
gathered  by  outflow  channels  to  the  long  rubber  tube,  which 
conducts  it  to  a  vessel  below  the  table. 

In  exceptional  cases  this  immediate  combination  of  dilatation 
and  irrigation  proves  useful.  But  the  instruments,  from  their 
very  construction,  require  the  hands  of  the  specialist  for  their 
use. 

The  technique  of  dilatations  is  the  same  for  all  dilators,  viz. : 

1.  After  the  instrument  is  in  the  necessary  position,  so  that 
the  region  known  to  be  diseased  embraces  the  branches  of  the 
dilator,  it  is  held  motionless  long  enough  to  allow  the  discom- 
fort of  its  presence  to  pass  off,  if  such  discomfort  is  experienced 
at  all.  This  varies  from  a  few  seconds  to  half  a  minute.  Dur- 
ing this  time  the  penis  is  held  steadily  by  the  left  hand  and 
drawn  out  its  full  length,  while  the  right  hand  keeps  the  dilator 
immovably  in  its  position. 

2.  Grasp  the  penis  with  the  four  left  fingers  and  palm,  and 
extend  the  left  thumb  to  the  ring  at  the  dilator's  handle,  thus 
holding  both  the  penis  and  the  dilator  immovably  together. 

3.  With  the  right  thumb,  index  and  middle  fingers  take  the 
large  screw-head  or  disc  at  the  handle  of  the  dilator  and  very 
gently  turn  it  to  the  right.  Continue  this  until  the  first  slight 
resistance  to  its  easy  progress  is  felt. 

4.  If  the  patient  is  not  extraordinarily  timorous,  it  will  then 
be  well  to  entrust  the  dilator  to  him  for  a  few  moments.  It 
occupies  his  attention  and  remeves  any  apprehension  he  may 


TREATMENT  OF  CHRONIC  GONORRHCEA.        161 

Lave  of  pain  tliat  may  be  produced.  At  tlie  same  time  it 
avoids  cramping  the  surgeon's  fingers  whicli  would  interfere  with 
further  delicate  dilatations.  The  patient  may  be  instructed  to 
avoid  cramp  by  holding  the  dilator  with  the  other  hand,  when 
the  one  grows  fatigued. 

5.  At  the  first  seance  leave  the  dilator  at  the  first  point  of 
resistance  for  from  three  to  five  minutes,  unless  an  especially 
spongy  mucosa,  as  evidenced  by  bleeding,  urethrospasm,  hyper- 
sesthesia,  or  fear  of  pain,  obliges  its  removal  before.  • 

6.  Close  the  dilator's  branches  by  very  slowly  turning  its 
screw-head  to  the  left.  In  doing  so,  watch  the  dial  and  turn 
the  screw-head  no  further  than  to  leave  it  open  one-half  or  one 
number  F.  to  preclude  the  very  remote  and  most  unusual,  but 
possible,  accident  of  a  collapse  of  the  rubber  cover  permitting  the 
branches,  if  closed  entirely,  to  grasp  the  urethral  mucosa. 

7.  Remove  the  Kollmann  anterior  dilator  by  drawing  the 
penis  back  with  the  left  hand  and  at  the  same  time  drawing  the 
dilator  from  the  urethra  with  the  right.  Remove  any  one  of  the 
other  dilators  by  tilting  the  anterior  margin  of  the  instrument 
as  if  to  dip  it  into  the  umbilicus ;  the  penis  will  then  drop  be- 
tween the  legs,  after  the  urethra  has  painlessly  slid  from  the 
rubber  cover. 

8.  After  each  dilatation,  irrigate  the  region  that  was  invaded: 
i.e.,  after  an  anterior  dilatation,  irrigate  the  anterior  urethra; 
after  a  posterior  dilatation,  irrigate  the  bladder.  The  solution 
most  frequently  employed  for  this  purpose  is  potassium  per- 
manganate 1  :  6,000.  In  some  cases  this  proves  quite  irritating 
after  dilatation;  then  it  may  be  used  at  one-half  this  strength, 
tIz.,  1  :  12,000  or  four-per-cent.  boric-acid  solution  may  be  sub- 
stituted. When  the  urethra  harbors  many  other  bacteria  besides 
gonococci  or  without  them,  silver  nitrate  1 : 5,000  or  1 : 3,000,  or 
stronger  if  it  can  be  borne,  will  be  found  effective. 

Irrigations  should  never  be  omitted  after  dilatations  or  in- 
deed any  urethral  instrumentation.  Without  them,  the  dis- 
charge is  materiallj^  increased  and  often  persists  several  weeks. 
Pain  on  and  even  between  urinations  may  become  quite  severe 
and  all  the  appearances  of  a  new  gonorrhoea  may  set  in.  The 
cause  thereof  is  evident.  If  gonococci  are  squeezed  from  the 
mouths  of  ducts  or  from  structural  interstices,  they  may  infect 
urethral  regions  that  had  returned  to  the  normal  state  or  that 
11 


162  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

had  remained  free  from  infection.  Tlie  results  of  omission  of 
irrigations  after  instrumentation,  if  they  portend  nothing  further, 
would  entail  a  delay  in  dilatations  until  the  reawakened  acute 
condition  has  yielded  to  additional  treatment. 

But  another  greater  and  more  immediate  danger  attends 
omission  of  irrigations ;  that  is,  urethral  fever  ("  catheter  fever  "). 
It  will  suffice  to  say  here  that  since  making  it  an  inflexible  rule 
to  irrigate  after  each  instrumentation,  not  a  single  case  of  ure- 
thral fever  has  resulted. 

Frequently  on  the  morning  after  a  dilatation  followed  by 
irrigation,  the  patient  will  find  a  slight  increase  of  the  discharge. 
If  this  continues  until  the  second  morning,  the  urethra  should 
be  again  irrigated  on  that  day ;  rarely  will  a  third  irrigation  be 
required. 

The  frequency  of  dilatations,  the  amount  of  dilatation  and 
its  duration  at  each  seance,  must  necessarily  be  governed  by  the 
condition  of  each  case,  the  toleration  of  the  patient,  and  the 
results  of  the  preceding  dilatations. 

A  good  average  working  rule  to  keep  within  the  limits  of 
safety  is :  (1)  Begin  with  two  dilatations  weekly ;  (2)  increase 
each  dilatation  one-half  number  F.  over  the  preceding  num- 
ber reached;  (3)  prolong  each  seance  two  minutes.  The 
longest  seance,  however,  a  patient  can  generally  endure  is 
forty -five  minutes.  Therefore  when  the  seances  have  reached 
this  limit,  the  dilatation  desired  must  be  attained  within  this 
time. 

Variations  from  the  above  may  become  necessary : 

1.  When  the  increase  of  discharge  persists,  as  it  may  in 
very  rare  cases,  beyond  three  days.  It  must  then  be  controlled 
by  irrigations. 

2.  When  marked  improvement  in  the  general  and  local  con- 
dition shows  that  the  intervals  between  dilatations  may  be  ex- 
tended. Experience  has  shown  that  recurrences  are  most  likely 
to  result  when  the  intervals  between  treatments  are  too  sud- 
denly made.  Therefore  the  extension  must  be  gradual.  Thus, 
for  instance,  if  a  patient  was  treated  on  Mondays  and  Thursdays, 
and  it  be  determined  on  a  Monday  to  extend  the  intervals  be- 
tween his  visits,  a  risk  would  be  incurred  by  asking  him  to  omit 
the  treatment  for  a  week.  Therefore  the  next  appointment  is 
made  for  Friday.     If  then  he  is  found  in  continued  improve- 


TREATMENT  OF  CHRONIC  GONORRHCEA.        163 

ment,  tlie  following  visit  is  set  for  "Wednesday,  and  eacli  inter- 
val increased  by  one  day  in  tLis  manner. 

3.  When  it  is  found  that  the  usual  increase  of  dilatation  by 
one-half  F.  over  the  preceding  number,  or  even  the  preceding 
number  itself  cannot  be  reached  without  producing  even  slight 
pain,  the  patient  may  explain  the  condition  by  an  intercurrent 
digression  into  the  paths  of  Venus  or  Bacchus  or  both.  "With- 
out such  an  occurrence  the  preceding  dilatation  may  have  pro- 
duced a  temporary  swelling  of  the  mucosa,  which  readilj^  sub- 
sides. The  physician,  when  such  an  impediment  presents, 
contents  himself  by  dilating  as  much  as  possible,  without  pro- 
ducing any  discomfort.  He  may  confidently  reassure  the  pa- 
tient that  the  time  lost  by  delay  in  progress  or  even  in  decrease 
of  the  progress  will  be  regained  in  a  few  sessions. 

4.  When  a  spongy  mucosa,  as  shown  by  blood  oozing  from 
the  meatus,  a  reawakened  hyperesthesia  or  urethrospasm  com- 
mand the  removal  of  the  instrument  before  the  time  required 
for  the  day's  dilatation,  the  latter  must  be  abbreviated. 

5.  When  a  dilatation  is  followed  by  oozing  of  blood  from 
the  meatus,  bloody  urination,  or  pain,  the  subsequent  dilatations 
must  be  increased  by  but  a  quarter  number  at  each  session.  If 
even  this  slow  procedure  is  still  followed  by  any  of  or  all  the  dis- 
turbances mentioned,  it  will  be  well  to  substitute  flexible  bougies 
for  the  dilator  until  the  use  of  the  bougie  no  longer  produces 
the  objectionable  symptoms.  The  bougie  selected  must  be  five 
numbers  F.  less  than  the  last  dilatation.  Thus  if  the  number 
reached  by  the  dilator  was  25,  the  bougie  to  take  its  place 
must  be  20,  or  a  size  as  much  smaller  as  will  g^ide  through  the 
urethra  easily  and  painlessly. 

While,  as  a  rule,  the  increase  of  dilatation  at  each  session  of 
one-half  number  F.  is  not  interrupted,  this  increase  should  never 
be  obtained  by  force.  Nor  should  the  beginner  attempt  to  ex- 
ceed this,  even  when  no  resistance  whatever  presents  thereto. 
Those  most  experienced  in  dilatations  prefer  the  slow  progress, 
because  of  the  greater  safety  it  assures. 

The  best  practice  is  to  stop  dilating  at  the  number  last 
reached  or  at  the  first  slightest  resistance,  and  then  at  from  three 
to  five  minutes'  intervals  to  dilate  at  no  more  than  half  numbers, 
or  up  to  slight  resistance,  until  the  number  desired  for  the  day 
is  attained. 


164  THE   IRRIGATION  TREATMENT   OF   GONORRHOEA. 

When  a  patient  observes  his  improvement  under  dilatations, 
lie  is  likely  to  urge  more  rapid  advances  than  above  directed. 
Such  patients,  when  not  watched,  are  tempted  to  surreptitiously 
give  the  dilator's  screw-head  a  rapid  turn.  Those  most  prone 
to  thus  viciously  maltreat  their  urethras  are  physicians  afflicted 
with  chronic  gonorrhoea.  Until  a  locking  device  is  invented 
that  will  iDrevent  such  patients  endangering  their  urethras,  it  will 
be  well  in  their  protection  to  refuse  a  continuance  of  treatment, 
unless  they  pledge  themselves  not  to  interfere  with  the  case. 

Bleeding  to  quite  a  considerable  extent  sometimes  follows 
dilatations,  especially  in  the  beginning  of  treatment.  Such  a 
hemorrhage  is  usually  of  very  short  duration;  if  it  threatens 
to  become  excessive,  the  penis  may  be  compressed  by  a  bandage 
until  it  ceases.  Obstinate  cases  may  require  the  pressure  of  a 
sound  within  the  urethra  in  addition  to  the  bandage.  This 
failing,  very  cold  water  passed  through  a  psychrophore  will,  in 
the  majority  of  instances,  arrest  the  bleeding.  In  extreme  cases, 
such  as  are  cited  on  page  77  (Complications),  the  urethra  may  be 
packed  in  the  manner  there  described.  When  bleedings  to  any 
extent  follow  dilatations,  it  will  be  well  to  endeavor  to  control 
erections  by  the  treatment  mentioned  on  page  47  (Chordee),  lest 
the  erections  cause  the  bleeding  to  recur  at  night. 

As  mentioned  before,  one  of  the  results  of  dilatations  is  an 
increase  of  discharge  on  the  morning  following  treatment,  or  its 
recurrence  if  no  discharge  existed.  Oberlaender  looks  upon 
this  as  an  evidence  of  the  "  melting  "  of  infiltrations.  However 
this  may  be  interpreted,  the  discharge  in  a  case  that  proceeds  in 
the  ordinary  manner  is  less  in  quantity,  thinner  in  consistence, 
and  lighter  in  color  at  each  recurrence,  until  it  ceases  entirely. 
The  products  of  inflammation  that  are  carried  off  in  the  urine 
become  smaller  and  less  in  quantity.  With  these  manifesta- 
tions the  general  condition  of  the  patient  improves  and  local  as 
well  as  reflex  manifestations  of  disease  fade  away. 

The  limits  of  dilatation  and  irrigation  are  reached  when  no 
more  evidences  of  disease  exist  or  can  be  evoked  by  the  tests 
mentioned  in  Chapter  XIV.  (The  Proofs  of  Cure  of  Gonorrhoea) . 

There  are  but  few  conditions  in  which  dilatations  are  contra- 
indicated.  Decrepit  persons,  those  in  acute  febrile  conditions, 
those  with  large  vesical  tumors  or  with  genito-urinary  tuber- 
culosis, or  those  in  whom  a  severe  posterior  urethritis  persists 


TREATMENT  OF  CHRONIC  GONORRHCEA.        1G5 

must  not  be  dilated.  The  last  mentioned  must  be  treated  by 
irrigations,  or  by  Guyon's  instillations  of  silver  nitrate,  until 
the  condition  of  the  posterior  urethra  ceases  to  be  an  impedi- 
ment to  dilatations. 

Invasion  of  the  crypts,  glands,  and  follicles  was  alluded  to  in 
this  chapter  under  the  third  class  of  causes  upon  which  the 
chronicity  of  a  gonorrhoea  may  depend.  In  such  a  case  dilata- 
tions and  irrigations 
will  have  no  appreci- 
able or  lasting  effect 
while  these  recesses 
harbor  infectious  bac- 

riG.  51.— KoUmann's  Urethral  Gland  Syringe.  teria.        Any    attempt 

to  treat  such  cases, 
except  locally,  by  means  of  the  urethroscope,  must  be 
abjectly  hopeless. 

Among  the  many  inventions  for  which  the  profession 
is  indebted  to  KoUmann  are  instruments  for  treating  these 
cases.  His  urethral  gland  syringe  is  the  first  to  be  con- 
sidered. By  means  of  this  little  instrument  silver  nitrate 
can  be  injected  directly  into  the  invaded  glands,  as  they 
are  exposed  by  the  urethroscope.  These  injections  fail- 
ing to  effect  a  cure,  the  glands  can  be  evacuated  by  his 
sharp  curette.  If  curettage  does  not  accomplish  the  de- 
sired end,  his  electrolytic  needle  will  effectively  destroy  the 
invaded  urethral  adnexa.  For  this  purpose,  the  needle 
is  attached  to  the  negative  pole  of  the  galvanic  battery ; 
the  positive  electrode  is  placed  firmly  upon  the  thigh. 
The  needle  is  then  carefully  inserted  into  the  gland  as  deeply 
as  is  possible  without  force ;  the  current  is  turned  on  verj^  slowly. 
At  two  or  three  milliamperes,  white  bubbles  will  be  seen  rising 
from  the  gland  about  the  needle;  as  the  instrument  is  sunk 
deeper  and  swept  about  the  gland,  these  bubbles  increase.  The 
surgeon  will  have  to  estimate  the  manipulations  required  to 
entirely  destroy  a  gland.  The  time  necessary  varies  from  five 
to  fifteen  seconds.  The  pain  of  electrolysis  is  easily  borne  by 
most  patients.  An  exceptionally  sensitive  case  maj-  require 
cocainization.  To  minimize  the  pain  the  current  should  not 
be  made  before  the  needle  is  inserted,  nor  should  the  needle 
be  removed  until  the  current  is  gradually  reduced  and  finally 


166  THE   IRRIGATION  TREATMENT   OF   GONORRHCEA. 

broken.  Ordinarily  not  more  than  three  or  four  glands  can  be 
destroyed  at  one  seance ;  even  if  the  patient  is  willing  to  bear 
the  prolonged  pain,  more  such  work  would  be  inadvisable, 
owing  to  the  excessive  reaction  that  would  thus  be  produced. 
The  greater  ease  and  safety  with  which  the  glands  can  be  de- 
stroyed by  electrolysis  makes  this  method  preferable  to  the 
intraglandular  injection  and  curettage  before  described.  The 
intensity  of  the  reaction  can  be  very  much  reduced,  and  often 


Fig.  52. — Kollmaim's  Electrolytic  Needle  for  the  Destruction  of 
•  Diseased  Urethral  Glands. 


entirely  obviated,  if  each  electrolytic  seance  is  followed  by  an 
irrigation,  as  should  be  every  instrumental  invasion  of  the  ure- 
thra. 

Neoplasms  of  the  urethra,  mentioned  in  this  chapter  as  the 
fourth  class  of  conditions  that  maintain  a  urethritis  chronic, 
are  not  amenable  to  treatment  except  by  aid  of  the  urethroscope. 
When  the^^  take  the  form  of  growths  upon  the  urethral  surface, 
they  must  be  removed,  as  directed  under  Complications  (page 
50) .  When  they  are  interstitial  as  well  as  superficial,  they  ap- 
pear as  dry,  gray-looking  cicatricial  masses.  Oberlaender 
recommends  splitting  these  with  his  urethroscopic  knife.  The 
necessity  of  resorting  to  such  incisions  has  not  presented  in  my 
experience.  Successive  punctures  of  such  infiltrates  with  KoU- 
mann's  electrolytic  needle,  each  seance  followed  by  an  irriga- 
tion, have  thus  far  sufficed  to  gradualh^  overcome  them.  The 
objective  point  is  usually  best  attained  by  treatment  twice  each 
week,  one  seance  devoted  to  electrolysis  and  the  other  to  dilata- 
tion. 

Invasion  of  the  urethral  adnexa,  placed  in  the  fifth  group  of 
causes  that  maintain  the  chronicity  of  gonorrhoea,  may  present 
as  Cowperitis,  vesiculitis,  or  prostatitis,  or  two  or  all  of  these. 
Their  treatment  is  sketched  under  Digital  Palpation  of  the 
Urethral  Adnexa,  page  173. 

Over-Treatment. — This  cause  for  the  continuance  of  a  chronic 
urethritis  has  not  been  considered  in  the  foregoing  groups. 


TREATaiENT   OF   CHRONIC   GONOERHCEA.  16T 

Yery  few  of  the  best-known  antliors  give  it  more  than  casual 
mention.  Among  these  Fiirbringer  emphasizes  the  fact  that 
the  urine  will  contain  filaments  as  long  as  the  urethra  is  dis- 
turbed by  instruments. 

If  a  urethra  that  had  never  been  infected  were  subjected  to 
persistent  instrumentation,  even  under  the  strictest  aseptic 
precautions,  it  would  sooner  or  later  resent  the  intrusion,  obedi- 
ent to  the  maxim  " uhi  irritatio,  ihi  affiuxus,"  if  not  otherwise 
than  by  irritative  urethritis. 

A  urethra  that  was  diseased  and  has  recovered  is  necessarily 
at  least  as  prone  to  be  affected  by  unnecessary  treatment.  If 
all  the  tests  advocated  in  Chapter  XIY.  (The  Proofs  of  Cure  in 
Gonorrhoea)  yield  a  negative  result,  the  physician  will  be  justi- 
fied in  discontinuing  treatment.  But  the  exigencies  of  general 
practice,  among  other  reasons,  i)revent  many  physicians  from 
becoming  sufficiently  expert  urethroscopists,  microscopists,  and 
chemical  analysts  of  urine  for  this  purpose.  The  test  that  then 
might  suggest  itself,  would  be  to  risk  discontinuance  of  treat- 
ment, with  intentions  to  resume  it  should  evidences  of  disease 
again  present.  This  would  be  as  dangerous  to  the  patient's 
health  as  it  would  be  to  the  physician's  reputation.  I  believe 
that  I  have  devised  a  fairly  effective  means  of  covering  such  cir- 
cumstances ;  this  means  is  suggested  when  discussing  the  inter- 
vals between  dilatations  (page  162).  Naturally  it  will  apply 
only  when,  for  any  reason,  the  direct  and  decisive  tests  of  cure 
cannot  be  made. 

This  suggestion  is  that  when  marked  improvement  shows 
itself,  the  intervals  between  treatments  be  prolonged  one  day 
each.  On  the  third  day  of  the  second  month  after  instituting 
such  extension,  the  patient  would  have  been  eight  days  without 
treatment.  If  he  continues  to  improve  during  this  interval,  the 
next  one  could  safely  be  made  twelve  days.  The  improvement 
still  continuing,  the  next  interval  could  be  eighteen  days.  This 
would  bring  the  case  to  the  third  day  of  the  third  month  of  in- 
stituting the  prolongation  of  intervals.  Thus  increasing  the 
intervals  between  treatments  by  one-half  each,  after  the  eight 
days'  interval  has  been  reached  in  the  ordinary  course,  would 
bring  the  next  day  of  treatment  twenty-seven  days,  or  nearly 
a  month  from  the  preceding  one. 


168  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Tlien  it  will  be  found  that : 

If  the  Urethra  is  still  Diseased :  If  the  Patient  has  Eecovered : 

On  the  day  after  ti'eatment  the  discharge  Recrudescence  of  the  discharge  may 

may  become    evident    again.     This  continue,  but  not  as  many  days  as 

may  continue  several  daj's.  it  would  in  a  still  diseased  condi- 
tion. 

The  floaters  in  the  urine  may  increase  Floaters  appear  in  the  urine  that  vras 

in  dimensions  and  numher  on  the  hitherto  clear.     They  are,  however, 

day  or  for  several  days  after  treat-  fine  and  few.    They  disappear  soon. 

ment ;  then  they  gi'ow  less  in  number 

and  smaller  in  dimensions,  but  do  not 

disappear. 

Toward    the  end  of   the  interval  be-  The  discharge  does  not  reappear,  nor 

tween  treatments  or  before,  the  dis-  does  any  abnormal   moisture  pre- 

charge  or  excess  of  moisture  may  re-  sent  at  the  meatus  ;  the  floaters  do 

appear;  the  "floaters"  in  the  urine  not  reappear. 

become  more    numerous    and    more 

gross. 

For  tlie  sake  of  emphasis  it  may  be  repeated  that  this  means 
of  establishing  the  need  of  continuance  or  cessation  of  treatment 
is  exceedingly  crude  and  prolonged,  but  it  is  offered  to  take  the 
place  of  the  other  correct,  scientific  method  when  the  latter  is 
not  available. 

X.    "RECURRENT"    GONORRHCEA. 

A  deliberately  intentional  misnomer  heads  this  chapter,  for 
the  purpose  of  grouping  under  it  the  recurrences  of  apparently 
cured  gonorrhoea  without  new  infection. 

A  recurrence,  with  or  without  an  exciting  cause,  soon  or 
many  years  after  a  clap  has  ceased  to  produce  any  manifesta- 
tions, is  but  a  symptom  of  residual  gonorrhoea.  Until  the  loca- 
tion of  the  residual  (latent,  quiescent)  affection  is  ascertained, 
the  disease  cannot  be  cured,  nor  the  patient  relieved  from  its 
dangers.  It  is  this  phase  of  gonorrhoea  that  has  misled  some 
good  men  to  deem  it  an  incurable  disease. 

Recurrent  gonorrhoea  certainly  offets  great  menaces  to  the 
patient  and  others,  mainly  because  of  the  fancied  security  in 
which  the  former  lives.  Deeming  himself  cured,  he  may  marry 
and  infect  his  wife,  or,  with  or  without  infecting  her,  the  disease 
maj^  recur  in  him  so  many  years  after  the  first  or  last  attack 
that  it  had  become  but  a  dim  shadow  of  the  past.     Unless  it  can 


"recurrent"  goxorrhcea.  169 

be  made  evident  that  lie  reinfected  himself,  a  family  disruption, 
because  of  the  presumption  of  infidelity  on  part  of  either  hus- 
band or  wife,  with  all  its  sad  consequences,  is  prone  to  result. 
This  is  especially  likely  to  be  the  case  if  gonococci  are  found 
in  the  wife's  genital  secretions. 

Few  physicians  indeed  there  are,  in  general  practice  or  in 
the  specialty,  who  have  not  seen  such  recurrences  of  gonorrhoea. 
They  present  the  appearances  of  a  new  infection  with  some  of 
or  all  its  symptoms  and  expose  the  patient  to  all  its  complica- 
tions and  sequelae. 

The  recurrence  of  such  an  uncured  gonorrhoea  may  be,  as 
said  before,  weeks,  months,  or  many  years  after  all  manifesta- 
tions of  the  disease  have  ceased. 

The  exciting  cause  may  be :  (1)  Reduction  of  the  patient's 
resistance  by  a  debilitating  disease,  by  exposure  to  inclement 
weather,  by  deprivation  from  proper  food,  by  physical  or  mental 
overwork,  by  prolonged  grief  or  anxiety ;  (2)  prolonged  excite- 
ment of  the  genitalia,  or  excessive  intercourse ;  (3)  dietetic  irregu- 
larity, such  as  di'inking  more  beer  or  other  stimulants  than  was 
the  patient's  custom;  (4)  a  traumatism  of  the  genitals,  provok- 
ing an  inflammatory  condition;  (5)  examination  of  the  prostate, 
seminal  vesicles,  or  Cowper's  glands,  when  urinary  disturbance 
causes  the  patient  to  seek  professional  advice ;  (6)  examination  of 
the  urethra,  as,  for  instance,  when  a  stricture  has  sufficiently 
advanced  to  impede  the  urinary  stream ;  (7)  marital  reinfection. 

Whatever  the  exciting  cause,  the  gross  manifestations  of  the 
disease  may  be  so  marked  and  the  appearance  of  gonococci  so 
characteristic  that  the  physician,  unless  he  knows  the  patient 
very  well,  might  believe,  even  if  the  patient  is  a  colleague,  that 
a  new  gonorrhoea  has  been  recently  contracted.  While  it  is 
true  that  the  infectious  incident  may  have  been  forgotten,  it  is 
better  to  err  on  the  side  of  charity  and  give  the  patient  the  bene- 
fit of  the  doubt. 

Irrigations,  as  described  in  Chapters  III.  and  V.,  will,  in  the 
majority  of  such  cases,  bring  about  an  abatement  of  the  disease, 
and  often  in  a  very  few  days.  But  the  cause  for  its  recurrence 
remains  and  is  likely  to  reproduce  it  at  any  time.  Therefore  it 
behooves  us  to  study  these  causes  now  as  far  as  is  compatible 
"within  the  limits  of  this  book. 

When  the  recurrence  is  provoked  by  reduction  of  resistance 


170  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

from  any  cause,  proper  nutrition,  protection  from  exposure  to 
atmospheric  inclemencies,  abstinence  from  overwork  must  be 
prescribed  in  addition  to  local  treatment.  Grief  and  anxiety 
are,  however,  beyond  the  sphere  of  professional  advice,  unless  it 
be  in  that  sympathy  and  encouragement  by  which  the  physician 
exercises  his  noblest  duty. 

In  addition,  these  cases  will  require  tonics.  After  several 
days  of  treatment,  microscopical  examination  of  the  discharge 
and  of  the  urine  will  serve  as  excellent  guides  to  the  locality  of 
the  residual  infection.  When  the  local  manifestations  have 
subsided  or  are  reduced  to  a  minimum,  exploration  of  the  ure- 
thra and  its  adnexa  will  usually  confirm  the  microscopical  diag- 
nosis. Before  the  case  can  be  dismissed,  these  must  be  treated, 
and  after  the  proper  interval,  the  patient  submitted  to  the  tests 
mentioned  in  Chapter  XIV.  (The  Proofs  of  Cure  of  Gonorrhoea). 

The  second  group  of  exciting  causes  of  a  gonorrhoeal  recur- 
rence are  perhaps  the  most  difficult  to  ascertain.  Few  married 
men,  except  those  lacking  culture  or  refinement,  will  confess  to 
genital  dalliance  with  a  partly  willing  female,  such,  for  instance, 
as  a  well-developed,  sensual-appearing  servant.  Yet  some  in 
whom  the  sexual  sense,  or  lack  of  sense,  is  strongly  pronounced 
are  guilty  of  such  acts,  in  which  they  perhaps  preserve  them- 
selves from  the  possible  consequences  of  infection  or  the  woman 
from  impregnation  by  abstaining  from  gratification  of  the  so 
stimulated  impulse.  A  step  further  in  this  class  is  shown  by 
those  who  indulge  in  psychic  masturbation.  They  give  way  to 
invoked  phantasms  of  sexual  relations  with  women  they  see  in 
public  ©r  even  with  creatures  of  the  imagination.  Whether 
these  practices  lead  to  appreciable  ejaculation  or  only  to  its 
verge,  the  effect  of  the  hypergemia  is  the  same. 

Those  who  had  sexual  intercourse  once  oftener  than  was  their 
habit  in  a  night  can  similarly  produce  an  emptying  of  gono- 
cocci  that  long  have  lain  residual  upon  the  urethral  mucosa,  or 
stimulate  them  to  renewed  activity  by  the  urethritis  ex  lihidine 
that  resulted. 

The  irritated  condition  of  the  urethra  which  often  obtains 
from  the  excesses  committed  shortly  after  marriage  may  pro- 
voke a  recurrence  of  gonorrhoea,  if  the  husband's  urethral  ad- 
nexa hold  gonococci.     An  illustrative  case  may  here  be  cited : 

A  gentleman,  aged  34,  acquired  gonorrhoea  in  his  eighteenth 


"recurrent"  gonorrhcea.  iTl 

year.  When  he  was  twenty-eight  he  married,  having  had  no 
manifestation  of  the  disease  for  ten  years.  Shortly  after  his 
marriage,  as  so  often  happens,  he  had  what  appeared  to  be  a 
very  severe  fresh  attack  of  gonorrhoea.  His  wife  was  similarly 
affected.  Conscious  that  for  six  months  before  he  had  not  ex- 
posed himself  to  infection,  and  his  wife  but  recently  having  been 
a  virgin,  he  attributed  their  illness  to  that  mysterious,  albeit 
often  quoted  cause,  a  "  strain, "  for  which  he  sought  no  treat- 
ment until  violent  orcho-epididymitis  bound  him  to  his  bed. 
It  progressed  to  suppuration,  which  caused  the  destruction  of 
one  epididymis  and  testicle. 

After  this  he  had  no  acute  evidence  of  disease  until  five 
years  later.  His  wife  then  had  returned  home  after  an  absence 
of  several  weeks.  Their  first  coitus  was,  within  four  days,  fol- 
lowed by  acute  gonorrhoea  in  both.  Never  having  been  guilty 
of  infidelity,  he  suspected  her,  with  the  usual  result  of  a  family 
disruption.  This  lasted  until  it  was  shown  him  that  either  or 
both  could  harbor  gonococci  for  years  without  any  appreciable 
manifestation  thereof.  In  both,  the  disease  yielded  rapidly  to 
irrigations.  The  wife,  on  subsequent  examination,  was  found 
to  be  free  from  the  disease.  The  husband,  however,  three 
weeks  after  responding  negatively  to  all  tests,  when  examined 
urethroscopically,  showed  some  enlarged,  gaping  glands.  Their 
contents  being  expressed  with  KoUmann's  spatula,  showed  gon- 
ococci, which,  with  an  adequately  exciting  cause,  would  have 
sufficed  to  produce  an  apparently  fresh  clap.  After  electrolysis 
of  these  glands  the  patient  resumed  relations  with  his  wife  and 
his  usual  mode  of  high  living.  Examination  of  the  entire  gen- 
ito-urinary  apparatus  six  months  later  showed  no  abnormal  con- 
dition, except,  of  course,  the  destroyed  testicle  and  epididymis. 

The  third  group  of  causes  for  the  recrudescence  of  residual 
gonorrhoea  are  those  attributable  to  dietetic  irregularities.  A 
glass  of  beer  or  wine  in  excess  of  the  usual  quantity  drunk,  or 
ingestion  of  the  vegetables  that  provoke  oxaluria  or  phosphaturia 
in  susceptible  cases,  may  set  up  enough  urethral  irritation  to 
reproduce  the  discharge.  In  Germany  the  urethral  irritation 
from  young  white  wine  and  beer  is  well-known  to  the  laity, 
whence  arose  the  familiar  designation  of  "  Biertripper. "  In  all 
the  cases  of  this  Biertripper  I  could  examine  gonococci  were 
found;  each  of  these  patients,  however,  acknowledged  having 
had  gonorrhoea.  No  doubt  can  obtain  but  that  such  a  distinct 
urethritis  occurs  in  cases  that  have  never  had  gonorrhoea;  it 
has,  however,  not  been  my  fortune  to  meet  one. 

When  such  a  urethritis  ah  ingestis  provokes  gonorrhoeal  re- 


172  THE    IRRIGATION  TREATMENT    OF   GONORRHCEA. 

currence,  success  in  ti'eatment  naturally  is  predicated  upon  pro- 
hibition of  all  irritating  food,  stimulants,  and  carbonated  waters. 

Traumatisms,  mentioned  before  as  the  fourth  class  of  causes 
for  the  recurrence  of  gonorrhoea,  explain  themselves.  It  is  not 
necessary  that  the  traumatism  to  the  genitals  be  applied  directly 
to  the  region  which  harbors  gonococci ;  the  inflammation  result- 
ing can  readily  extend  to  it  and  there  provoke  the  recurrence. 

The  fifth  division  of  cases  in  which  a  recurrence  of  gonor- 
rhoea is  provoked  is  distinctly  due  to  the  physician's  inevitable 
diagnostic  procedure,  as  shown  by  the  following  typical  outline : 
A  gentleman  beyond  middle  life  experiences  gradually  dimin- 
ishing propulsive  ability  in  expelling  urine.  The  physician 
examines  his  prostate,  and  in  so  doing  makes  pressure  upon  it. 
While  having  his  finger  in  the  rectum,  he  completes  his  work 
by  examining  the  seminal  vesicles  and  Cowper's  glands.  If  any 
of  these  adnexa  harbor  gonococci,  from  an  infection  of  possibly 
many  years  ago,  some  can  be  emptied  into  the  urethra  hy  the 
manipulations  necessary  for  a  thorough  examination.  Ordi- 
narily the  urethra  is  not  infected  thereby ;  but  if  there  be  a  point 
of  weakened  resistance  in  the  urethra,  acute  gonorrhoea  can  re- 
sult from  this  mode  of  infection. 

The  length  of  time  in  which  gonococci  can  be  harbored  within 
the  prostate,  without  in  any  way  manifestating  their  presence 
to  the  patient,  is  well  demonstrated  by  the  following  extreme 
case: 

A  gentleman  had  an  attack  of  gonorrhoea  in  his  eighteenth 
year.  At  twenty-six  he  married.  His  wife  bore  him  two  healthy 
children.  "W^en  he  was  forty-three  years  old,  his  wife,  who 
had  not  become  pregnant  for  ten  years,  was  taken  with  salpin- 
gitis at  about  the  same  time  that  he  became  affected  with  evidence 
of  prostatic  enlargement,  such  as  diminution  of  the  force  of  the 
stream,  frequent  nocturnal  urination  and  inability  entirely  to 
empty  his  bladder.  Examination  of  the  enlarged  gland  brought 
forth  a  very  small  quantity  of  grayish  muco-pus,  which  was 
found  replete  with  gonococci. 

So  here  is  a  case  in  which,  for  twenty -five  years,  the  prostate 
held  gonococci  without  any  manifestation  whatever,  not  even 
preventing  the  procreation  of  two  healthy  children. 

In  the  sixth  class  of  cases  auto-infection,  from  the  use  of  an 
exploring  instrument  to  discover  a  stricture  or  a  catheter  to  re- 
lieve retention,  is  far  more  readily  comprehensible.     The  instru-' 


DIGITAL   PALPATION   OF   THE   URETHRAL   ADNEXA.       lT3 

ment  can  impinge  upon  or  scrape  the  mouth  of  an  infarcted 
crypt,  gland,  or  follicle  and  thus  cause  gonococci  that  have  long 
lain  residual  therein,  to  be  set  free  upon  the  mucosa. 

The  seventh  set  of  cases,  those  in  which  gonorrhoea  is  due 
to  marital  reinfection,  are  mentioned  here  only  to  remind  the 
student  of  such  a  possibility.  The  importance  thereof  will  bet- 
ter be  considered  more  in  detail  under  Kesidual  Gonorrhoea  in 
Women  (Chapter  XII.). 

The  means  for  the  diagnosis  of  these  conditions  and  their 
treatment  are  outlined  under  the  respective  heads. 

Note  :  The  cases  cited  in  this  chapter  are  quoted  from  my 
report  in  the  Atlanta  Medical  and  Surgical  Journal,  for  Sep- 
tember, 1898. 


XI.    DIGITAL   PALPATION   OF    THE    URETHRAL 

ADNEXA. 

As  has  been  mentioned  under  the  Complications  of  Gonor- 
rhoea, the  posterior  urethra,  the  prostate,  and  the  seminal  vesicles 
frequently  become  involved  in  gonorrhoea.  Cowper's  glands 
often  escape.  If  infection  of  one  or  more  of  these  adnexa  is 
unheeded,  the  case  is  likely  to  be  interminable,  from  uninter- 
rupted or  occasional  reinfection  of  the  channel,  as  gonococci  are 
carried  to  it  from  the  organs  mentioned. 

A  greater  part  of  each  of  these  adnexa  can  be  reached  only 
through  the  rectum  by  the  finger,  not  alone  for  diagnostic,  but 
for  therapeutic  purposes  as  well. 

Digital  exploration  of  the  rectum,  disagreeable  and  even 
painful  as  it  sometimes  is,  cannot  be  avoided  in  the  diagnosis 
and  treatment  of  diseases  of  the  seminal  vesicles,  the  prostate, 
the  base  of  the  bladder,  Cowper's  glands,  and  the  posterior 
urethra. 

1.  Preparation  of  the  Patient. — "Whenever  possible,  the  ex- 
amination should  be  made  soon  after  the  patient  has  evacuated 
his  rectum.  The  presence  of  fecal  masses  or  of  a  column  of 
faeces  renders  the  examination  more  disgusting  than  necessary. 
It  also  has  a  tendency  to  divert  the  physician's  attention  from 
his  objective  points.  Many  patients,  especially  if  thej^  have 
not  defecated  on  the  day  of  the  examination,  at  once  have  a 


174         THE   lERIGATION   TREATMENT    OF   GONORRHOEA. 

desire  for  stool  when  the  finger  is  inserted.  The  straining  in- 
cidental thereto  may  thwart  the  effort  at  examination.  This 
maj'  go  so  far  as  to  oblige  an  interruption  of  the  examination, 
that  the  patient  may  go  to  the  closet.  The  immediate  resump- 
tion of  digital  exploration  thereafter  is  only  a  renewal  of  every- 
thing unpleasant  connected  with  the  procedure.  In  such  a  case, 
it  is  generally  advisable  to  defer  further  examination  to  the  fol- 
lowing day.  Of  course  such  prorogation  cannot  be  considered 
when  dealing  with  an  acute  case,  or  one  requiring  immediate 
treatment,  as  in  periprostatic  or  prostatic  abscess. 

2.  When  possible  the  patient  empties  his  bladder,  preferably 
into  two  or  three  twelve-inch  ignition  tubes.  Into  one  tube  ho 
passes  150  c.cgm.  (about  fl.  §  v.),  which  is  estimated  to  carry 
with  it  all  the  washings  from  the  anterior  urethra  that  can  be 
detached  by  the  stream.  The  second,  third,  or  more  tubes, 
according  to  the  capacity  of  the  bladder  and  the  time  that  has 
elapsed  since  the  last  urination,  should  then  be  filled.  The  last 
25  or  30  c.cgm.  (about  an  ounce)  should  be  voided  into  a  sepa- 
rate tube,  to  ascertain  whether  the  final  expulsive  efforts  cause 
ejection  of  the  contents  of  the  prostate  or  seminal  vesicles,  as 
in  urination-spermatorrhoea.  As  has  been  said  before,  separa- 
tion of  the  urine  in  this  manner  does  not  serve  for  absolute 
diagnostic  accuracy,  but  it  often  proves  a  valuable  aid  thereto. 

Naturally,  if  the  patient  is  severely  strictured,  or  has  incon- 
tinence from  any  cause,  or  retention  from  a  much  enlarged  pros- 
tate, this  preliminarj'  step  is  omitted. 

3.  Distending  the  Bladder.  ■ —  When  no  contraindication 
thereto  exists,  the  bladder  may  be  filled  with  a  warm  four-per- 
cent, boric-acid  solution.  Besides  distending  the  bladder  for 
the  purpose  of  facilitating  prostatic  examination,  this  is  the 
easiest  means  of  ascertaining  vesical  capacity.  Except  where 
a  large  prostate  acts  as  a  dam  for  residual  urine,  the  catheter 
and  hand  syringe  (such  as  the  Guy  on  or  Janet  syringes)  are 
preferable  for  such  measurement. 

The  use  of  boric  acid  for  this  purpose  has  other  advantages, 
which  will  be  mentioned  further  on  (see  14). 

4.  Position. — The  method  often  advocated,  of  bending  a  pa- 
tient over  a  chair  or  the  end  of  a  table,  is  unsatisfactory.  It 
obliges  the  surgeon  to  fix  the  pelvic  viscera  with  his  left  hand, 
adding  to  the  severe  labor  by  the  then  necessary  support  of  the 


DIGITAL   PALPATION   OF   THE    URETHRAL  ADNEXA.        l75 

abdomen.  As  many  of  the  cases  requiring  examination  and 
massage  of  the  prostate  are  quite  corpulent,  their  management 
in  this  position  becomes  impossible.  Moreover,  in  painful  pros- 
tatic conditions,  it  may  cause  a  patient  to  faint,  or  in  epileptics 
may  provoke  an  attack  during  examination. 

For  the  above  reasons  and  for  convenience  as  well,  it  is  best 
to  examine  all  cases  with  the  patient  lying  on  his  back  on  a 
couch  or  table,  the  knees  somewhat  raised,  and  the  heel  of  the 
right  foot  resting  in  the  hollow  of  the  left.  When  the  trousers 
are  then  drawn  down  to  the  ankles,  there  will  be  no  difficulty 
in  extending  the  knees  as  far  apart  as  possible.  A  cushion 
under  the  buttocks  is  objectionable,  as  it  throws  the  weight  of 
the  abdomen  upward,  which  draws  with  it  the  pelvic  viscera. 
In  so  doing  it  naturally  renders  the  distance  between  the  anus 
and  the  prostate  greater,  and  thus  unnecessarily  enhances  the 
difficulty  of  examination. 

Instead  of  a  cushion,  a  towel  should  be  placed  under  the 
buttocks  and  left  there,  while  the  shirt  is  drawn  up  to  beyond 
the  hips.  Most  prostatic  patients  are  very  susceptible  to  change 
of  temperature ;  the  towel  will  protect  their  bared  nates  from 
coming  into  contact  with  the  cold  leather  of  the  table  or  sofa. 
The  same  towel  should  be  used  by  the  patient  for  cleansing 
his  anus  of  the  lubricant  employed  in  the  examination.  The 
majority  will  appreciate  this  care  for  their  comfort  and  the 
cleanliness  of  their  linen.  They  will  also  appreciate  it  highly  if 
a  clean  towel  is  placed  under  their  heads,  so  that  the  hair  is  pro- 
tected from  contact  with  the  place  where  other  patients  have  lain. 

The  preference  for  a  sofa  over  a  table  for  prostatic  examina- 
tion lies  partly  in  the  fact  that  the  familiar  piece  of  furniture 
inspires  less  dread  than  does  the  more  strictly  surgical  imple- 
ment; consequently  there  is  less  likelihood  of  spasm  of  the 
sphincter  ani,  which  fear  of  pain  is  prone  to  induce.  Again, 
the  surgeon,  being  in  the  bent  posture,  can  exercise  greater 
thoroughness  with  less  manifestation  of  physical  effort  than  he 
could  if  the  patient  were  on  a  table. 

It  is  well  to  cover  the  lower  third  of  the  sofa  with  a  tough 
rug,  as  the  position  of  the  patient  with  his  knees  drawn  up  and 
extended  as  widely  apart  as  possible  exposes  his  feet  to  slip- 
ping, and  the  sofa  to  being  cut  or  at  least  mutilated  by  the 
patient's  heels. 


1T6  THE   IRRIGATION   TREATMENT   OF   GONORRHGEA. 

5.  Preparation  of  the  Finger. — For  some  time  I  used  espe- 
cially thin  rubber  cots  to  protect  tlie  index  from  contact  with  the 
rectum.  No  matter  how  thin,  they  always,  by  their  presence, 
obtund  sensation.  Then,  too,  the  thickened  band  at  the  open 
end  constricts  the  finger,  and  this,  producing  some  numbness  by 
venous  stasis,  also  renders  the  touch  less  acute. 

In  addition  to  thus  reducing  the  finger's  sensitiveness,  these 
cots  are  difficult  to  remove.  Even  slitting  them  with  a  probe- 
pointed  knife  does  not  prevent  the  fecal  soiling  one  sought  to 
avoid  by  their  use,  for  it  is  but  crowded  down  their  slippery 
surface  to  the  root  of  the  finger. 

After  discarding  the  finger-cots  I  for  a  while  used  short 
condoms  ("rubber  caps,"  Eichelcondome,  capotes  anglaises). 
The  touch  through  them  was  somewhat  better  than  through  the 
equally  thin  cots.  But  their  looseness  about  the  finger  often 
caused  them  to  be  swept  off  and  left  just  within  the  sphincter 
ani.  Attempts  to  fasten  them  with  rubber  bands  produced  the 
same  constriction  and  consequent  numbness  which  led  the  finger- 
cots  to  be  discarded.  Moreover  the  manufacture,  importation, 
or  sale  of  short  condoms  is  forbidden  by  law ;  therefore  there  is 
something  disagreeable  in  the  necessarily  surreptitious  manner 
of  obtaining  them. 

The  use  of  common  soap  for  the  finger  approaches  perfec- 
tion in  rectal  examination.  The  points  most  requiring  protec- 
tion are  the  sulcus  beneath  the  nail  and  the  matrix  at  its  base. 
Of  course  no  one  in  active  genito-urinary  work  thinks  of  begin- 
ning his  day's  labors  without  filing  and  pumice-stoning  his  nails 
as  close  to  the  skin  as  possible.  Still,  a  minute  subungual 
furrow  is  inevitable,  and  it  is  in  this  furrow  that  the  slightest 
trace  of  fecal  odor  makes  itself  so  unpleasantly  distinct,  even 
after  the  most  vigorous  scrubbing.  The  rival  of  this  spot  for 
fecal  defilement  is  the  slightly  overhanging  skin  at  the  matrix 
of  the  nail,  which,  despite  the  most  assiduous  trimming,  cannot 
be  kept  down  or  even.  Most  genito-urinary  practitioners  who 
treat  many  cases  daily,  wash  and  scrub  their  hands  very  many 
times  during  office  hours.  It  is  true  that  at  one  of  the  large 
European  clinics  I  saw  a  gentleman  with  a  little  bowl  before 
him,  containing  about  eight  ounces  of  1:1,000  mercuric  bi- 
chloride solution.  After  each  patient  he  dipped  the  tips  of  his 
fingers  into  this  bowl  and  dried  them  on  a  towel — the  one  towel 


DIGITAL   PALPATION   OF   THE   URETHRAL   ADKEXA.      lYY 

serving  liim  for  perhaps  a  liundrecl  cases.  That  lie  did  not 
infect  himself  or  carry  infection  from  one  patient  to  another 
could  have  been  but  a  matter  of  luck.  The  matrices  of  his  nails, 
too,  were  just  as  ragged  as  if  he  had  used  as  much  hot  water 
and  soap  as  do  others. 

When  soap  is  used  to  protect  the  finger,  the  cake  should  be 
slightly  moistened  and  then  scraped  with  the  index,  in  such  a 
manner  as  to  fill  the  matrix,  as  well  as  the  i?aterval  between  the 
nail  and  the  skin  at  the  tip  of  the  finger.  But  after  this  is 
scrubbed  off  ever  so  vigorously  and  thoroughly,  a  match  or 
ioothpick  scraped  through  these  spaces  will  acquire  a  decided 
fecal  odor.  This  is  possibly  due  to  some  of  the  excremental 
constituents  penetrating  the  soap. 

"When  soap  is  used  for  this  purpose,  the  finger  can  be  rid  of 
its  bad  smell  by  first  thoroughly  scrubbing  it  in  intensely  hot, 
running  water;  then  crushing  a  few  grains  of  potassic  perman- 
ganate about  the  finger  with  the  left  hand.  After  the  ozone- 
like smell  of  the  permanganate  becomes  evident,  the  stain  is 
removed  with  oxalic  acid  and  numerous  rinsings.  The  slight 
cuts  and  chaps  one  occasionally  acquires  despite  the  greatest 
care  then  become  too  painfully  evident  to  pass  unobserved. 

Since  January,  1899, 1  have  used  flexible  collodion  for  finger 
protection  in  rectal  examinations  of  the  genito-urinarj'  adnexa. 
Tt  covers  the  finger  tip  with  a  pellicle  which,  if  properly  ap- 
plied, does  not  break  within  the  rectum.  It  in  no  wise  obtunds 
sensation.  The  fingerfe  els  through  it  as  acutely  as  if  it  were 
not  covered  at  all.  Only  after  the  examination,  when  the  finger 
is  vigorously  scrubbed  with  soap  and  very  hot  water,  does  the 
collodion  separate  and  then  in  large  flakes.  These  flakes  are 
five  or  six  times  thicker  than  elsewhere,  at  the  subungual  space 
and  at  the  matrix,  the  very  points  most  easily  invaded  by  rectal 
contents.  Any  bits  of  collodion  that  may  remain  are  quickly 
removed  by  a  little  ether,  which  also  dissolves  the  fats  that  hold 
the  minute  fecal  masses  adherent  to  the  finger.  Thus  cleanli- 
ness after  rectal  exploration  is  easily  obtained. 

The  best  manner  of  securing  a  desirable  coat  for  the  finger 
is  by  dipping  it  into  an  ounce  salt-mouth  containing  the  flexible 
collodion.  As  soon  as  the  first  coat  has  dried,  a  second  and 
finally  a  third  may  be  applied  in  the  same  manner.  This  will 
give  additional  security  and  not  interfere  with  sensation. 
12 


178  THE    IRRIGATION    TREATMENT    01"    GONORRHCEA. 

Special  care  should  be  exercised  in  not  attempting  to  insert  the 
finger  before  all  parts  of  its  collodion  covering  are  perfectly  dry . 
It  may  require  several  minutes  to  insure  solidity  of  the  little 
blebs  that  form  between  the  finger  and  the  collodion.  If  these 
are  overlooked  and  the  finger  is  inserted  while  they  still  exist, 
they  will  break  in  the  rectum  and  produce  severe  burning  as  the 
ether  of  the  collodion  touches  the  mucosa.  Besides  the  un- 
necessar.y  suffering  thus  inflicted  upon  the  patient,  the  points  at 
which  the  collodion  has  so  been  broken  will  cause  it  to  peel  off 
in  shreds  and  leave  the  finger  exposed  to  contamination  by  the 
fecal  odor. 

6.  Protecting  the  Genitals. — The  patient  being  in  position, 
with  his  trousers  and  drawers  well  drawn  down  to  his  ankles, 
as  described  under  4,  the  surgeon  raises  the  scrotum  with  his 
left  hand,  so  that  the  genitalia  be  not  unnecessarily  soiled  with 
the  lubricant  that  is  now  applied  to  the  collodion-covered  finger. 

7.  Lubricating  the  Finger  and  Anus. — When  the  entire  right 
index  finger  is  coated  with  collodion,  as  much  lubrichondrin  as 
can  be  taken  up  by  it  is  placed  upon  the  anus. 

8.  Inserting  the  Finger. — Most  of  the  works  I  have  been  able 
to  search  are  exceedingly  meagre  in  their  description  of  the 
entire  technique  of  rectal  digital  examination.  The  most  ex- 
plicit are  Hoffmann,  Giiterbock,  and  von  Friscli. 

The  first '  says :  "  The  examining  index  finger,  its  vola  turned 
upward,  well  oiled,  is  slowly  inserted  with  gyrating  motions, 
into  the  anus,  after  a  thorough  evacuation  of  the  rectum." 

Giiterbock"  offers  but  little  more  detail:  "The  oiled,  care- 
fully inserted  finger  feels,  after  traversing  the  excavation  of  the 
rectum  that  lies  closely  over  the  anus,  first  the  bulb  which  offers 
somewhat  increased  resistance." 

These  directions  certainly  suffice  for  surgeons  v/ho  have  been 
well  instructed.  But  not  all  have  had  the  educational  advan- 
tages that  make  further  details  superfluous. 

Professor  von  Frisch,"  who  describes  the  lower  rectal  findings 

lEgon  Hoffmann:  "Die  Krankheiten  der  Prostata."  Zuelzer  and  Ober- 
laender's  Klinisclies  Handbiich  der  Harn-  imd  Sexualorgane,  vol.  iii.,  p.  3, 
Leipzig,  1894. 

2  Paul  Giiterbock  :  Die  Krankheiten  der  Harnrohre  uud  Prostata,  p.  203, 
Leipzig  and  Vienna,  1890. 

2 A.  von  Friscli:  Die  Krankheiten  der  Prostata,  Holder,  Vienna,  1899. 


DIGITAL  PALPATION  OF  THE  URETHRAL  ADNEXA.   179 

more  in  detail,  offers  tlie  valuable  advice  that  the  hairs  about 
the  anus  be  separated  before  attempting  to  insert  the  finger. 
This  additional  precaution  against  giving  the  patient  pain  by 
dragging  the  hairs  into  the  rectum  will  be  especially  appreci- 
ated by  those  who  have  been  examined  before  without  this  care. 
Moreover,  the  examination  will  be  easier  to  the  physician  be- 
cause of  the  absence  of  the  pain  which  dragging  upon  the  hairs 
would  produce  and  the  anal  rigidity  it  would  evoke. 

It  is  hardl}^  necessary  to  call  attention  to  the  need  of  care- 
fully avoiding  an}-  fissures  or  erosions  about  the  anus,  lest  pain 
be  given  and  aggravation  of  these  conditions  produced  thereby. 

The  examiner's  index  finger,  protected  with  flexible  collodion, 
penetrates  the  mass  of  lubricant  he  has  placed  upon  the  anus. 
At  the  moment  of  an  interval  between  expiration  and  just  before 
beginning  inspiration,  he  allows  the  finger  to  glide  into  the 
rectum.  Anj  hesitation,  gyration,  or  force  wdll  cause  the  pa- 
tient to  contract  the  sphincter  and  violently  clasp  the  thighs  to- 
gether. The  patient  will  certainly  esteem  more  the  efforts  of 
one  who,  causing  less  or  no  pain,  consequently  performs  better 
and  more  thorough  work. 

9.  Beleasing  the  Scrotum. — The  left  hand  now  being  required 
to  fix  the  pelvic  viscera,  it  allows  the  scrotum  to  fall  gentl}^ 
into  the  space  between  the  right  thumb  and  the  extended  right 
index  finger. 

10.  Fixing  the  Pelvic  Visceyxi. — The  left  hand  is  curved,  the 
outer  margin  of  the  thumb  placed  about  half  an  inch  above  and 
parallel  to  the  pubis.  By  increasing  pressure  downward  and 
backward,  the  pelvic  contents  are  rendered  as  immovable  as 
l)0ssible  and  approached,  as  far  as  can  be,  to  the  finger  within 
the  rectum. 

11.  Baising  the  Perineum. — When  the  index  finger  is  about 
to  approach  the  mass  of  lubricant  on  the  anus  the  middle,  ring, 
and  little  fingers  are  flexed ;  when  the  index  penetrates  the  rectum, 
the  other  fingers  are  tightly  closed  upon  the  palm.  The  dorsal 
aspect  of  their  basilar  phalanges  presses  against  the  perineum 
as  the  index  ingresses  more  deeply  into  the  rectum.  Mean- 
while the  forearm  is  depressed  between  the  thighs  until  the 
elbow  almost  touches  the  couch  upon  which  the  patient  lies.  As 
this  is  being  done  the  perineum  is  crowded  upward^  the  surgeon 
avoiding  contact  with  the  tip  of  the  coccyx. 


180  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

12.  Position  of  the  Thumb. — If  the  thumb  is  doubled  with 
the  other  fingers,  it  will  be  arrested  by  the  ascending  ramus  of 
the  pubis  and  thus  materially  limit  the  upward  progress  of  the 
index  within  the  rectum.  When  the  hand  is  turned  to  avoid 
this,  the  knuckle  of  the  thumb  will  impinge  upon  the  anterior 
part  of  the  perineum  and  give  the  patient  unnecessary  pain.  It 
is  therefore  well  to  pass  the  thumb  as  high  up  as  possible  along 
the  scrotum,  while  the  index  finger  glides  into  the  rectum. 

13.  Faljjation. — The  index  finger,  as  it  progresses  into  the 
rectum,  ordinarily  finds :  (a)  the  excavation  of  the  rectum,  almost 
immediately  above  the  anus ;  (h)  the  bulb  which  offers  a  some- 
what increased  resistance;  (c)  the  pars  nuda  urethrse;  (d)  the 
apex  of  the  rectal  surface  of  the  prostate;  (e)  the  lobes  of  the 
prostate. 

Even  a  short  index  finger,  when  the  proper  technique  is 
carefully  followed,  can  pass  its  tip  about  the  topmost  margins 
of  the  prostate  and  even  beyond  them,  as  in  health  the  extreme 
upper  curves  of  the  prostatic  lobes  are  between  7  and  8  cm.  from 
the  external  anal  margin. 

With  increasing  practice  the  physician  will  learn  to  seek  for 
the  seminal  vesicles  and  the  ampullae  of  the  vasa  beyond  the 
prostate,  and  Cowper's  glands  below  it,  during  the  same  rectal 
exploration.     Ordinarily  these  adnexa  cannot  be  found  in  health. 

If  prostatic  enlargement  always  proceeded  in  its  rectal  direc- 
tion alone,  digital  palpation  would  suffice  for  diagnosis.  But 
as  the  diseased  prostate  can  increase  in  size  in  any  direction, 
other  palpatory  means  than  that  furnished  by  the  finger  will  be 
required. 

In  this  a  silver  catheter  with  a  short  curve  or  with  the 
Mercier  beak  will  prove  of  valuable  aid.  If,  the  finger  being  in 
the  rectum,  such  a  catheter  is  inserted  into  the  bladder,  its  tip 
is  distinctly  felt  as  it  passes  through  the  bulbous  portion  and 
with  equal  distinctness  as  it  penetrates  the  pars  nuda.  It  then 
disappears  until  its  tip  proceeds  just  beyond  the  prostate.  A 
tight  rubber  band  may  then  be  slipped  over  the  catheter  just 
where  it  emerges  from  the  meatus,  while  the  penis  is  crowded 
as  far  back  toward  the  pubis  as  possible.  Then  withdrawing 
the  catheter,  its  point  is  concealed  by  the  prostate  from  the 
finger  in  the  rectum.  Still  further  extracting  the  catheter,  an- 
other rubber  band  is  slipped  over  its  shaft  at  the  moment  when 


DIGITAL   PALPATION    OF   THE   URETHRAL   ADNEXA.       181 

the  finger  witliin  tlie  rectum  first  feels  it  in  the  pars  nucla,  be- 
neath the  prostate.  The  distance  between  the  two  rubber  bands 
will  give  a  sufficiently  precise  measurement  of  the  length  of  the 
prostatic  urethra.  This  consequently  will  also  reveal  increase 
in  the  length  of  the  prostate. 

The  thickness  of  the  prostate  and  variations  therein  are, dis- 
cernible in  the  same  manner.  An  aid  to  this  is  in  close  obser- 
vation of  the  shaft  of  the  catheter.  Grossly  it  may  be  said  that 
the  less  the  prostate  crowds  into  the  bladder,  the  more  will  the 
external  end  of  the  catheter  point  upward,  and  the  larger  the 
prostatic  ingression  of  the  bladder,  the  more  will  it  be  inclined 
downward  between  the  patient's  thighs.  Naturally  this  applies 
only  when  the  shaft  of  the  catheter  has  passed  the  prostatic  ure- 
thra. 

The  cysroscope  is  doubtless  the  most  valuable  instrument 
for  prostatic  examination,  when  its  encroachment  is  principally 
toward  the  bladder.  But  as  cystoscopy  is  not  within  the  prov- 
ince of  the  present  effort,  we  may  rest  at  its  mention. 

14.  Emptying  the  Bladder.— The  discomfort  at  least,  if  there 
be  no  severe  pain  incidental  to  rectal  palpation,  ordinarily 
affects  the  patient  very  much.  Often  the  pupils  will  be  found 
quite  dilated,  the  pulse  weak,  and  respiration  disturbed.  Some 
men  grow  very  pale  and  are  suffused  with  persi)iration  in  con- 
sequence of  the  examination.  It  is  well  to  have  the  patient 
remain  in  the  position  of  the  examination,  but  with  extended 
legs,  for  at  least  five  minutes,  or  at  all  events  until  all  symp- 
toms of  the  disturbance  have  passed  off.  He  is  then  allowed  to 
rise,  and,  in  order  to  divert  his  attention,  he  is  ordered  to  cleanse 
carefully  the  region  about  his  anus  of  the  lubricant  lest  it  soil 
his  linen. 

It  will  be  unwise  to  ask  the  patient  to  empty  his  blad- 
der at  once.  The  examination  ordinarily  produces  a  pro- 
longed spasm  of  the  compressor,  which  does  not  subside  for 
five  or  ten  minutes,  and  only  then  can  the  patient  void  the  blad- 
der contents. 

15.  Microscopical  Examination. — When  boric-acid  solution  or 
sterilized  water  has  been  used  to  dilate  the  bladder,  it  shows  by 
its  turbidity,  when  passed,  that  the  prostatic  contents  or  those 
of  the  seminal  vesicles  have  been  pressed  out  during  the  ex- 
amination.     If  the  palpation  has  been  prolonged,  the  water 


182  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

may  also  contain  a  little  urine.  Shreds  from  the  bladder  or 
urethra  may  also  float  in  the  liquid.  To  complete  the  diag- 
nosis, the  fluid  should  be  sedimented  or  centrifuged  and  ex- 
amined microscopically.  By  this  means  a  guide  to  the  organ 
affected  will  be  obtained. 

If  the  prostate  is  not  so  much  enlarged  as  to  preclude  sepa- 
rate examination  of  the  other  urethral  adnexa  that  can  be  reached 
through  the  rectum,  these  should  be  examined  preferably  a  day 
or  two  after  each  other.  While  their  shape  and  gross  changes 
can  be  elicited  at  one  examination  when  extreme  prostatic  en- 
largement does  not  prevent,  the  contents  expressed  from  them 
are  mingled  in  the  urethra,  and  therefore  the  specimens  obtained 
must  be  examined  together. 

The  technique  of  separate  examination  of  each  of  the  other 
urethral  adnexa  is  performed  as  follows : 

16.  Seminal  Vesicles. — All  the  steps  for  examination  of  the 
prostate  are  taken.  The  finger  passes  the  prostate  without 
making  any  pressure  upon  it.  Above  the  prostate  and  some- 
what external  to  its  sides,  the  vesicles  project  along  the  bladder. 
In  health  the  vesicles  cannot  often  be  felt ;  in  disease  they  pre- 
sent as  somewhat  enlarged  sausage-shaped,  soft  or  hard  bodies. 
Occasionally  distinct  knots  are  felt  in  them.  Their  stripping 
or  "  milking  "  is  performed  by  strokes  similar  to  those  used  in 
massage  of  the  prostate.  Fuller's  excellent  work  on  "  Disorders 
of  the  Male  Sexual  Organs  "  (Lea,  1895)  is  devoted  to  the  study 
of  diseases  of  the  seminal  vesicles,  and  to  this  work  the  reader 
is  referred  for  exhaustive  information. 

17.  The  Posterior  Urethra. — For  examination  of  as  much  of 
the  posterior  urethra  as  can  be  reached  through  the  rectum,  the 
patient's  bladder  is  first  irrigated  until  the  boric  acid  used  is 
returned  perfectly  clear.  Then  the  bladder  is  filled  with  dis- 
tilled water,  and  the  patient  prepared  as  for  a  prostatic  examina- 
tion. The  examining  finger,  however,  leaves  the  prostate  without 
pressing  upon  it,  and  exercises  all  its  pressure  on  such  parts  of 
the  urethra  as  are  exposed,  endeavoring  at  each  stroke  to  com- 
press the  urethra  more  closely  against  the  pubis.  The  distilled 
water  then  passed  will  contain  such  shreds,  flakes,  filaments, 
and  granules  as  the  urinary  stream  and  irrigation  could  not  de- 
tach from  the  walls  of  the  posterior  urethra.  While  the  pres- 
ence of  gonococci  in  this  "  expression  fluid  "  will  serve  to  assist 


DIGITAL   PALPATION   OF   THE   URETHRAL   ADXEXA.       183 

in  diagnosis,  differentiation  is  not  complete  without  uretliro- 
scopic  examination. 

18.  Coicpers  Glands. — Altliougli  these  glands  are  not  fre- 
quently involved,  their  examination  should  not  be  omitted.  In 
health  they  are  so  minute  as  to  be  barely  or  not  at  all  percepti- 
ble to  the  examining  finger  in  the  rectum.  When  it  is  engaged 
between  the  internal  and  external  sphincter,  somewhat  doubled 
UTiou  itself  and  carried  forward  in  the  direction  of  the  perineal 
I'aphe,  at  either  side  thereof,  these  glands  will  be  found. 

In  many  cases  of  prostatic  enlargement,  of  acute  vesiculitis 
or  cystitis,  the  bladder  will  not  tolerate  the  preliminary  disten- 
tion mentioned  above.  The  examination  then  must  be  made 
without  this  valuable  assistance,  and  it  consequently  becomes 
more  difficult. 

It  is  particularly  when  the  bladder  is  dilated  that  some 
of  the  contents  of  the  adnexa  escape  from  the  meatus  when 
pressure  is  made  upon  them.  The  discharge  so  obtained  is 
then  easily  taken  upon  a  cover-glass,  and  prepared  for  micro- 
scopical examination. 

Massage  of  tJie  prostate  and  striijping  the  seminal  vesicles  for 
therapeutic  purposes  are  performed  in  practicalh^  the  same  man- 
ner. The  tip  of  the  finger  engages,  as  high  up  as  possible, 
the  organ  to  be  treated.  At  first  gentle,  slow  strokes  downward 
and  toward  the  mesian  line  are  made ;  these  strokes  are  gradu- 
ally' increased  in  firmness  and  continued  until  the  flattening  of 
the  organs  shows  that  their  removable  contents  are  expressed,  or 
at  least  as  long  as  the  patient  can  bear  the  manipulation. 

In  many  cases  the  efficacy  of  prostatic  massage  can  be  en- 
lianced  by  steadying  the  vesical  side  of  the  prostate  by  means 
of  a  sound,  preferably  of  the  Guyon  curve.  It  requires,  how- 
ever, some  dexterity  to  so  incline  the  sound  laterally  within  the 
bladder  that  it  rests  upon  and  thereby'  to  a  degree  fixes  the 
prostatic  lobe  that  is  being  treated  through  the  rectum. 

The  student  need  hardly  be  reminded  that  the  first  rectal 
manipulation  is  likely  to  be  quite  painful.  Therefore  extreme 
gentleness  is  as  requisite  here  as  it  is  in  all  other  genito-urinary 
work.  The  relief  patients  experience  is  in  most  instances  so 
great  th^t  they  willingly  submit  to  what  soon  grows  to  be  a 
mere  inconvenience.  Indeed,  many  of  them  urge  its  repetition 
at  shorter  intervals  than  the  judgment  of  the  physician  prescribes. 


184  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

Only  rarely  can  these  organs  bear  massage  or  stripping  oftener 
than  twice  or  at  most  three  times  weekly.  In  exceptional  cases 
daily  massage  may  be  required. 


XII.    RESIDUAL   GONORRHOEA  IN  WOMEN. 

Gynecologists  have,  in  recent  years,  well  exposed  the  dis- 
astrous consequences  of  gonorrhoea  when  it  invades  the  womb 
and  the  organs  beyond.  They  have  also  shown  how  amenable 
the  disease  is  to  treatment  before  it  has  passed  beyond  the 
vagina. 

Many  a  woman,  however,  subjected  to  the  older  methods  of 
treatment  is  only  apparently  cured.  In  consequence,  she  may 
at  any  time  near  or  remote,  infect  a  man,  if  the  circumstances  are 
projjitious  therefor.  This  form  of  the  disease,  which  seems  to 
be  best  defined  hj  the  term  "residual  gonorrhoea,"  has  appar- 
ently not  received  the  attention  in  literature  that  its  importance 
merits. 

In  considering  residual  gonorrhoea  in  women,  the  disease 
adulterously  acquired  by  the  husband  or  wife  may,  in  certain 
cases,  be  within  the  range  of  possibility.  But  adultery  does  not 
contribute  to  the  understanding  of  residual  gonorrhoea,  unless 
the  infection  of  the  husband  occurs  long  after  all  manifestations 
of  the  attack  have  subsided. 

Again,  the  possibility  of  auto-infection  on  the  part  of  the 
husband,  who  had  gonorrhoea  before  marriage,  as  outlined  in 
Chapter  X.,  can  explain  a  gonorrhoea  in  his  wife,  who  may,  if 
the  husband  is  ignorant  of  such  a  possibility,  be  unjustly  ac- 
cused of  infidelity. 

The  field  for  speculation  and  theorization  in  this  connection 
is  extremely  wide,  and  most  frequently  no  conclusions  can  be 
reached  therefrom.  Certain  facts,  however,  are  known.  Among 
these  are  the  not  inconsiderable  number  of  women  who  marry 
men  while  the  latter  are  not  cured  of  gonorrhoea.  Many  of 
these  women,  for  at  least  a  period  of  their  lives,  enjoy  a  species 
of  immunity.  Their  resistance  to  gonorrhoeal  infection  may  at 
any  time  become  impaired  by  slight  causes.  If  the  case  re- 
ceives prompt  and  energetic  treatment,  no  residual  gonorrhoea 
will  result. 


RESIDUAL   GOXORRHCEA    IN   WOMEN.  185 

Many  practitioners  have  been  obliged  to  treat  vaginitis  in 
recently  married  women.  Often  this  is  so  slight  that  it  subsides 
with  the  employment  of  an  antiseptic  wash,  a  lead  and  opium 
lotion,  or  injections  only  of  hot  water.  Since  familiarity  of  prac- 
titioners with  bacteriological  staining  has  become  greater,  many 
of  these  cases  are  found  to  contain  gonococci.  Anti-gonorrhoeal 
treatment  being  employed,  the  patients  recover. 

The  majority  of  brides,  however,  do  not  inform  any  one  of 
their  ailments,  which  they  conclude  are  the  natural  consequences 
of  sexual  intercourse.  In  very  many  cases,  especially  if  the 
husband  is  considerately  abstinent  for  a  while,  the  infection  ap- 
parently yields  to  the  vis  medicatrix  naturce. 

In  some  cases  the  inflammation  is  so  slight  and  its  resultant 
discharge  so  scanty  that,  when  gonococci  are  found  in  the  mi- 
nute excess  of  normal  secretion,  Guiard's  hlennorrhagie  clironique 
d'emhUe  is  suggested. 

Most  women,  when  brought  for  examination  under  suspicion 
of  having  infected  their  husbands,  will  unhesitatingly  acknowl- 
edge having  had  leucorrhoea  once  or  oftener  in  their  lives. 
Some,  however,  have  had  so  slight  vaginal  discharges  that  they 
attracted  no  attention  because  of  that  marvellous  carelessness 
regarding  the  genitals  which  so  widely  extends  in  all  classes  of 
society.  Whether  these  discharges  were  the  result  of  gonor- 
rhoeal  infection  or  were  leucorrhoeas  due  to  other  causes,  is  of 
course  impossible  to  determine  after  they  have  passed  off. 

The  cases  that  must  be  considered  as  residual  present  no  ex- 
ternal manifestations  whatever.  The  urethra,  the  labia,  the 
vagina,  the  cul-de-sac,  and  the  os  all  appear  perfectly  normal. 
If  consideration  of  the  woman's  health  stops  here,  and  the  hus- 
band is  cured,  he  is  likely  at  any  time  to  again  contract  the  dis- 
ease from  his  wife,  without  any  crass  evidences  of  the  disease 
becoming  manifest  in  her. 

To  illustrate  as  graphically  as  is  possible  to  me,  the  condi- 
tions above  outlined,  I  transcribe  several  typical  cases  from  my 
records : 

J.  B aged  35,  banker,  in  apparent  good  health,  with  no 

family  or  personal  record  of  disease  of  any  kind,  was  sent  by 
a  colleague  on  November  5th,  1897.  The  patient  said  that 
for  three  years  he  had  been  cohabiting  with  but  one  woman, 
of  whose  fidelity  he  had  no  doubt.     Three  weeks  before,  he  had. 


186         THE   IRRIGATION   TREATMENT    OF   GOXORRHCEA. 

four  days  after  intercourse,  experienced  slight  burning  on  uri- 
nation f  soon  a  slight  mucoid  excess  set  in.  The  discharge 
rapidly  became  yellowish,  then  greenish-yellow,  mixed  with 
blood.  With  the  increase  of  the  discharge  the  pain  on  urination 
increased ;  painful  erections  were  almost  continual  every  night ; 
the  right  epididymis  was  enlarged,  not  much  hardened,  but  ex- 
quisitely sensitive.  The  last-mentioned  complication  caused 
him  to  be  referred  to  me.  The  patient  had  been  treated  by  the 
internal  administration  of  balsams  and  various  hand  injections. 

On  examination  of  the  discharge  it  was  found  to  contain 
very  little  mucus,  few  leucocytes,  few  epithelial  cells,  and  most 
of  these  from  the  second  layer  of  the  urethra.  Everywhere  the 
field  was  thick  with  pus  cells,  of  which  many  seemed  ready  to 
burst  from  their  repletion  with  gonococci.  There  were  also 
man^^  extracellular  gonococci  between  the  pus  cells  and  some 
attached  to  the  epithelial  scales. 

In  brief,  it  was  a  distinct  case  of  gonorrhoea.  Irrigations 
and  strapping  the  testicle  enabled  the  patient  to  be  dismissed 
from  treatment  on  November  23d,  1897— i.e.,  eighteen  days  after 
his  first  visit.  Beer  and  champagne  did  not  reproduce  the  dis- 
charge; injection  of  silver  nitrate  produced  a  non-microbic  dis- 
charge lasting  ten  hours ;  coitus  with  a  condom  showed  the 
semen  to  be  normal;  expression  of  the  prostate  and  seminal 
vesicles  proved  freedom  from  infection  of  these  organs ;  these 
tests  were  made  a  week  apart.  Then,  a  week  later,  a  urethro- 
scopic  examination  showed  a  healthy  urethra. 

On  March  20th,  1898,  the  patient  was  again  sent  to  me  with 
some  pain  on  urination,  slight  mucoid  discharge  easily  express- 
ible from  the  somewhat  tumefied  lips  of  the  meatus.  The  first 
urine  was  turbid  and  contained  coarse  filaments,  which  sank 
rapidlj^  to  the  bottom.     The  second  urine  was  clear. 

Microscopical  examination  of  the  discharge  showed  it  to  con- 
tain several  groups  of  intracellular  gonococci. 

The  patient  assured  me  that  he  had  cohabited  with  no  other 
woman.  His  last  intercourse  had  been  four  days  previously, 
being  two  days  before  she  began  to  menstruate,  at  which  epoch 
she  was  more  than  ordinately  sensual.  They  had  not  committed 
sexual  excesses. 

Under  irrigations  this  discharge  and  all  other  symptoms 
ceased  in  five  days. 

During  this  time  he  told  me  that  his  mistress  confessed  to 
having  been  unfaithful  to  him  about  six  months  before,  with  a 
married  man,  whom  he  knew.  The  one-time  partner  of  his 
mistress's  favors  confirmed  her  confession,  but  averred  that  he 
never  had  had  any  venereal  disease. 

I  suggested  that  if  my  patient  had  never  been  infected  be- 
fore, possibly  his  mistress  had,  previous  to  their  acquaintance, 
and  that  she  might  unconsciously  be  carrying  a  residual  gonor- 


RESIDUAL   GOXORRHCEA   IX   WOMEN.  IST 

rhoea,  whicli  from  the  liyperEemia  incidental  to  the  pre-  and 
post-menstrual  days  would  become  manifest.  He  then  wrote 
her,  severing  their  relations.  She  came  to  his  office  and  in  tears 
Adolently  protested  against  being  cast  off.  In  the  heat  of  her 
asseverations,  she  confessed  to  having  cohabited  with  a  number 
of  men,  whose  names  she  revealed,  so  that  he  might  assure  him- 
self that  none  of  them  had  been  infected  by  her. 

On  her  insistence  that  she  be  examined  in  his  presence,  he 
brought  her  to  me. 

To  safeguard  vaj  position  regarding  what  might  otherwise 
imply  a  violation  of  professional  confidence,  I  asked  whether 
she  were  willing  that  I  tell  him  my  findings  in  her  presence. 
To  this  she  promptly  consented. 

On  examination,  I  found  her  genitalia  in  apparently  per- 
fect health.  Careful  scrapings  from  the  introitus,  Bartholini's 
glands,  the  meatus,  the  vaginal  walls,  the  cul-de-sac,  the  cervix, 
all  showed  normal  epithelium,  some  mucus,  and  the  usual  vaginal 
bacteria. 

I  then  carefully  irrigated  the  genitalia  with  hot  boric-acid 
solution,  sterilized  my  hands,  and  packed  the  vagina  with  steril- 
ized' cotton  tampons  soaked  in  sterilized  glycerin.  On  re- 
moving these  forty-eight  hours  later,  I  found  a  slight  excess  of 
whitish  discharge  upon  the  small  tampon  that  had  rested  in  the 
cul-de-sac  and  some  slight  oozing  from  the  os.  Examination  of 
these  discharges,  so  evoked  from  the  submucous  layers,  was 
found  to  contain  distinct  groups  of  gonococci. 

The  patient  then  told  her  lover,  in  my  presence,  that  about 
a  year  before  she  first  knew  him,  she  had  had  a  slight  vaginal 
discharge,  which  had  been  diagnosed  as  leucorrhoea;  this  had 
promptly  yielded  to  treatment.  As  an  explanation  for  infecting 
him  and  not  others,  she  offered  that  he  was  the  only  one  with 
whom  she  experienced  an  orgasm,  while  she  merely  submitted 
to  the  others  for  the  sake  of  financial  gain. 

A  similar  case  was  brought  me  three  years  ago. 

A  young  married  woman  infected  her  lover.  She  confessed 
to  having  been  cured  of  gonorrhoea  acquired  as  a  result  of  her 
first  adultery,  while  her  husband  was  on  a  long  voyage.  He 
was  never  infected  by  her.  She  said  that  though  her  husband 
was  sexually  more  potent  than  her  lover,  and  physically  better 
developed,  he  never  produced  an  orgasm  in  her.  This  she  at- 
tributed to  her  dislike  for  him.  Each  coitus  with  her  lover, 
however,  was  complete. 

Examination  revealed  an  exceedingly  slight  endocervicitis 
which,  however,  contained  no  gonococci.  Only  upon  curetting 
the  cervix,  some  discharge  was  obtained  containing  Neisser's 
specific  microbe  of  gonorrhoea.     In  this  case  it  seemed  safe  to 


188  THE   IRRIGATION^  TREATMENT   OF   GONORRHCEA. 

say  tliat  tlie  spasm  of  the  orgasm  discLargecl  in  this  instance 
gonococci,  which  reached  the  lover's  meatus. 

In  a  third  case,  seen  with  a  colleague,  the  patient  was  a 
young  woman,  who  claimed  to  suffer  from  occasional  eroto- 
mania. When  the  condition  was  severe  she  assumed  the  part 
of  a  prostitute.  Frequent  cohabitation  did  not  relieve  the  de- 
sire, unless  the  man's  physique  or  mentality  especially  pleased 
her.  Then  coitus  produced  an  orgasm.  She  was  sure,  when- 
ever this  occurred,  that  she  had  infected  the  man.  Her  phy- 
sician told  me  that  she  had  sent  him  a  number  of  patients,  for 
whose  treatment  she  had  paid,  whenever  the  patient  would  per- 
mit it.  She  unhesitatingly  related  that  she  had  had  gonorrhoea^ 
four  years  previous  to  consultation. 

Examination  evinced  no  excess  of  secretion,  but  a  thorough 
curettage  revealed  that  the  deeper  uterine  mucosa  harbored 
gonococci.  This  young  woman,  though  continuing  her  course, 
afterward  infected  no  others. 

A  number  of  similar  cases  could  be  thus  sketched  to  warrant 
the  following  deductions : 

(1)  A  woman  can  have  residual  gonorrhoea,  without  any  ex- 
ternal manifestations.  (2)  A  woman  with  residual  gonorrhoea  is 
more  likely  to  infect  a  man  cohabiting  with  her  during  the  hy- 
persemia  immediately  preceding  or  still  remaining  after  men- 
struation. (3)  The  likelihood  of  infection  is  probably  greater  if 
the  coitus  produces  an  orgasm  in  the  woman.  (4)  Packing  the 
cul-de-sac,  as  employed  in  the  first  case  cited,  may  produce  a 
slight  discharge,  revealing  the  submucous  habitat  of  gonococci. 
(5)  A  submucous  intra-uterine  habitat  of  gonococci  can  be 
reached  only  by  thorough  curettage.  (6)  No  woman  should  be 
pronounced  cured  of  gonorrhoea  until  the  osmosis  test  men- 
tioned above  (4)  has  proved  negative,  and  until  expression  of 
the  urethra  and  Bartholini's  glands,  and  scrapings  from  the 
cervix  and  uterine  lining  are  proven  to  be  free  from  gonococci. 

Note  :  This  chapter  is  elaborated  from  an  article  I  contrib- 
uted to  the  American  Journal  of  Surgery  and  Gynecology  (St. 
Louis),  May,  1898. 

XIII.    URETHROSCOPY. 

As  has  been  repeatedly  observed  in  the  preceding  chapters,  a 
diagnosis  of  a  chronic  urethral  disease  cannot  be  even  approxi- 
mately complete  without  visual  examination  of  the  channel. 


URETHROSCOPY.  189 

Obedient  to  surgical  principles,  no  instrument  may  be  in- 
troduced into  tlie  urethra  wMle  it  is  acutely  inilamed.  -Tlie  only 
exceptions  thereto  are  when  a  foreign  body  requires  removal  or 
when  retention  demands  relief  by  the  catheter,  after  other  means 
of  voiding  the  bladder  have  failed. 

In  Chapter  '\rLEI.  (Chronic  Gonorrhoea)  mention  was  made 
of  the  fact  that  without  the  aid  of  the  urethroscope,  all  treat- 
ment of  chronic  urethral  diseases  must  be  tentative.  With  its 
assistance,  the  diagnosis  can  be  made  early,  the  treatment  di- 
rected to  the  cause,  and  recovery  expedited. 

But  as  easy  as  urethroscopy  is,  and  as  simple  as  its  tech- 
nique has  become,  it  can  be  acquired  only  most  laboriously 
from  written  descriptions.  The  certainty  of  diagnosis  it  gives, 
however,  is  worth  all  the  efforts  devoted  to  acquiring  it.  In 
this  it  does  not  differ  from  other  instruments  of  precision,  such 
as  the  ophthalmoscope,  the  laryngoscope,  etc.,  except  that  its 
manipulations  are  less  difficult. 

The  technique  of  urethroscopy  can  be  most  readily  acquired 
by  a  few  lessons  from  a  colleague,  who  has  been  properly  in- 
structed. A  recognition  of  the  multifarious  conditions  seen  and 
their  diagnostic  interpretation  can  come  only  with  experience. 
All  efforts  to  pictorially  present  the  urethral  conditions  have 
hitherto  failed,  at  least,  in  being  of  use  to  the  beginner.  The 
essential  difficulty  seems  in  the  reproduction  of  the  colors, 
which  are  seen  in  the  urethra  under  electric  illumination.  The 
pictures  lithographed  all  appear  too  lurid,  when  an  attempt  to 
reproduce  them  is  made.  Exceptions  thereto  are  the  sectional 
colored  pictures  illustrating  Oberlaender's'  work,  but  as  they  are 
schematic,  showing  the  walls  of  the  urethra  in  section,  they  are 
of  use  only,  and  of  most  valuable  use,  to  the  urethroscopist  of 
some  experience.  KoUmann's  black  and  white  photographs  of 
the  urethra  are  also  invaluable  to  the  advanced  urethroscopist; 
it  would  certainly  be  desirable  if  the  method  of  photographing 
the  urethra  devised  by  him  were  in  the  hands  of  all  genito-uri- 
nary  specialists,  whose  records  and  reports  would  be  vastly  en- 
hanced in  value  thereby. 

The  reasons  wherefor  the  urethroscope  is  not  more  generally 
used  seem  to  be  because:   (1)  Of  the  complicated  character  of 

•  Oberlaender :  Lehrbucli  der  Urethroskopie,  Thieine,  Leipzig,  1893. 


190  THE    IRRIGATIOX   TREATMENT    OF   GOXORRHCEA. 

tlie  instruments  for  direct  illumination ;  (2)  of  defective  light- 
ing; (3)  of  the  high  cost  of  the  instrumentarium. 

The  consequence  is,  that  the  treatment  of  chronic  gonorrhoea 
continues  to  be  with  some  the  most  unhappy  guesswork.  To 
others  it  is  a  hopeless  task,  undertaken  with  misgivings  and 
discarded  in  desperation.  What  wonder  then  that  the  quacks 
make  this  their  favored  field,  to  begin  with  promises,  to  end 
with  the  patient's  purse  !  The  immense  number  of  men  whose 
lives  are  rendered  miserable  and  abbreviated  by  chronic  gonor- 
rhoea, make  all  efforts  on  their  behalf,  and  on  behalf  of  their 
wives  and  children,  worthy  of  most  serious  consideration. 

Manifestly  then,  an  instrument  is  necessary  to  show  the 
practitioner  the  exact  location  and  precise  character  of  the  dis- 
ease. The  instrument  must  effectively  do  its  work,  must  be 
simple  in  construction,  eas^'  of  use,  not  prone  to  get  out  of  order, 
and  always  reliable. 

If  the  opinion  of  those  who  honor  me  by  calling  me  their 
fellow-specialist  is  a  guide,  as  it  is  on  other  matters,  all  these 
ends  are  accomplished  by  the  urethroscope  I  had  the  privilege 
of  publicly  demonstrating  for  the  first  time  before  our  Genito- 
urinary Section  of  the  New  York  Academy  of  Medicine  on 
March  14th,  1899. 

This  instrument,  made  for  me  by  the  Electro-Surgical  Com- 
pany, consists  of  uretkroscopic  tubes,  running  from  Nos.  24  to  32 


Fig.  53.— Drethroscoplc  Tubes. 

F.  In  general  appearance  they  differ  little  from  the  Nitze-Ober- 
laender  tubes  with  burnished  ends  as  modified  by  Kollmann. 
This  modification  permits  urethral  examination  from  behind  for- 
ward as  well  as  from  before  backward.  The  disc  at  the  visual 
end  is,  however,  larger,  to  safely  hold  the  spur  for  easy  and  firm 
attachment  of  the  light-carrier  and  the  megaloscope. 

Each  tube  is  provided  with  an  obturator,  stamped  on  the 
handle  to  correspond  with  the  tube  to  which  it  belongs.  The 
distal  end  closes  the  urethral  tube  to  permit  its  easy  introduc- 


URETHROSCOPY 


191 


tion,  and  has  a  deep  slit  corresponding  witli  a  similar  slit  in 
the  handle.  This  slit  permits  air  to  readily  enter  the  tube, 
facilitating  the  removal  of  the  obturator  by  then  preventing  any 
suction  upon  the  urethral  mucosa. 


Fig.  .54. — obiurdtor. 


The  Ught-carrier  is  a  delicate  but  very  firm  strip  containing 
the  insulated  wires  that  illuminate  the  lamp  which  is  enclosed 
in  a  glass  capsule.  By  this  means  bright  light  is  brought 
into  almost  immediate  contact  with  the  spots  to  be  examined,  be 
they  ever  so  small.  At  its  proximal  end  the  light-carrier  has 
an  expansion,  which  can  readily  be  attached  to  the  spur  on  the 
disc  of  the  urethroscopic  tube.  From  the  expansion  the  in- 
sulated connections  for  the  conducting  wires  project,  but  are  so 


FIG.  6.3.— Light-Carrier. 

curved  that  they  do  not  encroach  upon  the  visual  orifice  of  the 
urethral  tube. 

The  light-carrier  in  general  appearance  resembles  the  one 
used  in  the  Nitze-Oberlaender  urethroscope.  It  differs  essen- 
tially, however,  in  that  the  lamj)  gives  no  appreciable  heat,  and 
consequently  requires  none  of  the  cumbersome  water-cooling 
arrangements  that  are  necessary  when  an  uncovered  light  is  used. 
Furthermore,  the  lamp  being  fixed  permanently  at  its  end,  is 
not  exposed  to  twisting  and  short-circuiting,  as  happens  almost 
continually  with  what  hitherto  was  the  best  instrument  for  direct 
illumination.  Nor  is  this  lamp  likely  to  burn  out,  unless  the 
most  gross  carelessness  is  employed. 

Moreover,  the  light  being  enclosed  in  glass,  permits  the  lamp 
to  remain  in  place  while  swabbing  the  secretions  from  the  urethra, 
performing  cauterizations,  slitting  infiltrated  glands,  electrolysis, 
finding  the  opening  of  devious  strictures,  and  every  other  diag- 
nostic and  remedial  procedure,  all  under  the  guidance  of  sight. 


192 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


The  megaloscope  is  a  series  of  lenses  combined  in  a  sliort 
tube,  attachable  by  a  ring  to  the  spur  on  the  disc.  By 
means  of  the  megaloscope,  whose  focus  is  easily  changed,  the 
view  of  every  part  of  the  urethra  can  be  im- 
mensely magnified.  The  intersi)ace  between 
the  visual  orifice  of  the  tube  and  the  objective 
end  of  the  megaloscope  is  three-fourths  of  an 
inch,  to  allow  the  introduction  of  instruments 
for  operative  procedures  within  the  urethra. 

The  urethroscope,  with  all  the  appurte- 
nances described,  is  enclosed  in  a  case,  whose 
total  weight  is  about  ten  pounds.  At  the  price 
at  which  the  fresh  dry  cells  are  furnished,  the 
cost  of  each  urethroscopy  is  within  half  a  cent. 

The  foregoing  shows  that  I  have  devised 
only  improvements  upon  and  mainly  simplifica- 
tions of  existing  instruments.  This  urethroscope 
in  its  entirety,  however,  differs  from  the  Nitze- 
Oberlaender  apparatus  in  being  easily  transport- 
able, thus  making  it  unnecessary  to  reserve  a 
room  in  the  office  suite  for  this  purpose,  or  of  having  an  urethro- 
scopic  outfit  for  each  room. 

When  science  and  benefit  to  humanity  are  objective  points, 
the  question  of  priority  is  of  no  importance.  Still  it  may  be 
well  to  sketch  the  history  of  this  instrument.  In  1894 1  expressed 
to  my  friend  and  fellow-student,  Dr.  Henry  Koch,  the  opinion 
that  urethroscopy  by  direct  illumination  would  not  find  favor 
with  the  profession  unless  the  water-cooling  arrangement  could 
be  dispensed  with  and  the  apparatus  further  simplified  as  to  the 
source  of  illumination  and  in  other  regards.  It  seemed  to  me 
that  the  first  step  in  this  direction  would  be  in  the  production 
of  a  sufficiently  small  encapsulated  light.  Late  in  1898  Dr. 
Koch  found  that  Mr.  W.  C.  Preston  could  make  such  a  light. 
Experiments  with  it  led  me  to  suggest  the  construction  of  the 
apparatus  above  described.' 

The  technique  of  urethroscopy ,  as  suggested  before,  is  exceed- 

1  As  this  book  is  going  to  press,  Messrs.  George  Tiemann  &  Company,  of 
New  York,  are  placing  before  the  profession  a  urethroscopic  apparatus  embrac- 
ing all  the  improvements  that  continued  study  and  experience  have  demon- 
strated to  be  necessary  for  aseptic,  effective,  and  convenient  work. 


URETHROSCOPY.  193 

ingly  simple.  One  demonstration  usuallr  suffices  to  impart  all 
its  details.  As,  however,  all  cannot  avail  themselves  of  such 
personal  instruction,  an  attempt  is  here  made  to  substitute  it, 
as  well  as  m}^  descriptive  powers  will  allow. 

Anterior  Urethroscopy. — 1.  Have  the  patient  lie  on  an  oper- 
ating-table, or  sit  on  a  high  chair.  The  former  is  always  pref- 
erable, especially  when  an  intra-urethral  operation  is  to  be  per- 
formed or  when  remedies  are  to  be  applied.  When  a  chair  is  used 
the  patient  should  sit  as  far  forward  as  possible  upon  its  front 
edge,  its  back  supporting  his  shoulders,  and  his  legs  wide  apart. 

2.  Cleanse  the  foreskin,  glans,  and  meatus  thoroughly  with 
absorbent  cotton  soaked  in  bichloride  1 : 6,000. 

3.  Select  the  urethroscopic  tube  that  will  readily  pass  the 
meatus.  Those  experienced  in  urethroscopy  will  have  no  diffi- 
culty in  doing  this.  The  novice  will  do  well  to  employ  a  Piffard 
meatometer,  w^hich  often  reveals  that  a  meatus  which  appears  to 
be  very  tight  is  rapidly,  painlessly  extensible  so  that  it  will 
offer  no  resistance  to  a  very  large  tube.  On  the  other  hand,  it 
will  often  show  that  quite  a  large  meatus  is  no  guide  to  a  very 
tight  posterior  boundary  of  the  fossa  navicularis.  In  the  latter 
case,  a  much  smaller  tube  must  be  used  or  a  preliminary  deep 
meatotomy  performed. 

4.  After  cleansing  the  tube  and  obturator,  pass  each  one 
separately  through  the  flame  of  an  alcohol  lamp  or  Bunsen 
burner.  Then  insert  the  obturator  into  the  tube  and  pour  gly- 
cerin upon  them  until  the  tube,  and  especially  the  projecting 
tip  of  the  obturator,  is  thoroughly  lubricated. 

5.  Take  the  penis  in  the  left  hand  as  for  anterior  irrigations 
and  wipe  upon  the  meatus  some  of  the  excess  of  the  glycerin 
from  the  tube  in  the  same  manner  as  was  recommended  before 
(insertion  of  a  dilator,  vide  page  153). 

6.  Insert  thej;ube  gently,  without  any  gyrating  motions, 
until  it  is  arrested  by  the  compressor  urethras  or  the  anterior 
layer  of  the  triangular  ligament.  If  it  does  not  proceed  so  far 
without  the  employment  of  force,  stricture  or  some  other  abnor- 
mality obstructs  its  progress.  Then  a  smaller  tube  must  be 
used.  Only  exceptionally  is  there  any  practical  value  in  em- 
ploying a  tube  smaller  than  a  24  F.,  save  by  urethroscopic  ex- 
perts. A  tube  so  large  as  to  give  pain  or  to  produce  excessive 
bleeding  thwarts  the  purposes  of  urethroscopv. 

13 


194         THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

7.  Withdraw  the  obturator,  after  giving  it  a  slight  turn  in 
either  direction. 

8.  Dry  the  urethra  of  excessive  secretions  by  gently  mop- 
ping it  through  the  tube  by  means  of  applicators  wrapped  with 
absorbent  cotton.  Uncut  match  sticks  will  be  found  most  con- 
venient for  this  purpose. 

9.  Insert  the  light-carrier,  and  fasten  it  to  the  spur  on  the 
disc. 

10.  Attach  the  megaloscope  when  required. 

11.  Draw  the  tube  slowly  out  of  the  urethra.  As  this  is 
being  done  all  its  parts  fall  into  view.  When  one  requiring 
special  investigation  or  treatment  is  met,  bend  the  penis  over 
the  tip  of  the  tube  in  the  direction  opposite  to  the  side  at  which 
the  point  to  be  examined  appears.  This  stretches  the  mucosa 
at  such  a  point  for  better  examination  or  treatment.  The  fourth 
or  fifth  finger  of  the  left  hand  holding  the  penis  can  push  the 
urethra  still  further  into  view. 

12.  As  an  additional  safeguard,  it  is  well  to  irrigate  the  an- 
terior urethra  after  a  urethroscopy,  as  after  any  other  instru- 
mentation. 

Posterior  Urethroscopy. — (a)  Place  the  patient  in  the  posi- 
tion for  perineal  section. 

(b)  Perform  the  steps  indicated  above  (1  to  6).  When  the 
tip  has  reached  the  compressor  make  gentle  pressure  against  it; 
at  the  same  time  depress  the  tube  between  the  thighs.  Then, 
watching  for  the  end  of  an  expiration,  gently  thrust  the  tube 
inward  and  slightly  upward.  Usually  the  grasp  of  the  com- 
pressor is  felt  upon  the  tube  for  an  instant ;  immediately  there- 
after it  can  be  drawn  forward  and  backward.  This  should  not 
be  done  bruskly  lest  the  tip  injure  the  very  sensitive  posterior 
urethra. 

(c)  Withdraw  the  obturator.  This  is  usually  followed  by 
some  urine. 

{d)  Dry  the  posterior  urethra  as  much  as  possible  with  ab- 
sorbent cotton  wrapped  about  applicators,  taking  more  care  than 
ever  to  use  no  violence.  A  little  blood  upon  the  cotton  is,  how- 
ever, not  unusual. 

(e)  Insert  the  light-carrier.  Even  if  urine  trickles  into  the 
posterior  urethra  and  out  through  the  urethroscope,  it  will  not 
extinguish  the  light,  as  it  would  were  an  uncovered,  incandescent 


URETHROSCOPY.  195 

wire  employed.  Tlie  posterior  uretlira  can  consequently  be 
most  deliberately  examined,  its  secretions  mopped  up,  and  ap- 
plications made  under  the  guidance  of  sight. 

An  intravesical  irrigation  of  potassium  permanganate 
1:6,000,  or  of  boric  acid  four  percent.,  should  be  used  after 
posterior  urethroscopy. 

UrethroscopiG  Diagnosis. — The  recognition  of  urethral  dis- 
turbances, lite  a  knowledge  of  the  urethra  in  health,  cannot  be 
acquired,  except  most  laboriously,  from  mere  descriptions.  Even 
such  graphic  details  as  those  furnished  by  Oberlaender,  Koll- 
mann,  and  Wossidlo  are  of  use  only  to  the  urethroscopist 
whose  eye  has  received  some  training.  They  then  are  invalu- 
able. 

Still,  those  who  are  prevented  from  obtaining  personal  in- 
struction in  the  urethroscopic  appearances  are  entitled  to  such 
guidance  as  is  within  the  writer's  power.  To  this  end  the  fol- 
lowing attempt  is  made. 

Tlie  Uretlira  in  Health.  — Even  when  observing  most  scrupulous 
asepsis  no  physician  will  insert  an  instrument  into  a  urethra 
which  he  knows  to  be  in  health.  But  the  practitioner  may  avail 
himself,  for  the  purpose  of  studying  the  normal  urethra,  of  a 
class  of  neurasthenics  to  whose  general  condition  urethroscopy 
acts  as  a  most  grateful  placebo.  ISTo  matter  how  perfect  the 
condition  of  their  urinary  channels,  nor  how  firm  the  physician 
is  in  assuring  them  of  that  fact,  they  are  satisfied  and  believe 
themselves  improved  with  each  urethroscopic  examination. 

The  study  of  urethroscopy  on  cadavers  is  absolutely  useless. 
Circulation  having  ceased,  the  natural  color  and  consistence  of 
the  mucosa  are  gone  and  offer  no  means  for  comparisons. 

A  first  glance  into  the  normal  urethra  shows  a  red  glare,  re- 
calling one's  initial  effort  at  ophthalmoscopy.  After  some  prac- 
tice one  learns  to  distinguish  brilliancy,  colors,  folds,  and  stri£e. 
The  normal  "  central  figure,"  as  Oberlaender  calls  that  part  of  the 
urethra  which  presents  when  the  tube  is  held  in  the  exact  axis 
of  the  canal,  merits  study,  as  do  the  mouths  of  the  crypts  which 
later  on  become  evident  to  the  investigator.  Under  the  megalo- 
scopic  attachment  the  submucous  blood-vessels  become  visible; 
their  normal  or  excessive  tortuousness  should  receive  heed. 

Even  with  these  premises  it  will  be  found  that  the  urethra, 
like  other  organs,  varies  exceedingly  within  the  limits  of  health. 


196       the  irrigation  treatment  of  gonorrhcea. 

The  Normal  Anterior  Urethra. 

The  normal  brilliancy  of  the  urethra  varies  in  its  different 
parts.  The  cavernous  portion  is  so  brilliant  that  it  suggests 
disturbing  reflexes.  The  fossa  is  perhaps  almost  as  brilliant, 
but  the  paleness  of  its  submucous  tissues  makes  the  whiteness 
thereof  more  apparent. 

The  lyyrmal  color  varies  considerably.  It  m&j  be  anaemic, 
pale,  or  light  pink;  moderately  hypersemic,  roseate  to  red;  hy- 
persemic,  intensely  red. 

The  normal  folds  vary  with  the  calibre,  thickness,  and  con- 
sistence of  the  urethra.  A  narrow  ansemic  urethra  shows  slight 
folds  or  none  at  all ;  while  a  wide,  thick,  coarse  urethra  contains 
five  to  eight  more  or  less  deep  folds  of  mucosa. 

The  normal  strice  appear  as  fine  yellowish- white  marks,  radi- 
ating from  the  central  figure  upon  the  eminences  of  the  folds. 
This  striation  is  not  found  in  all  urethrae. 

The  normal  central  figure  suggests  the  opening  of  a  rubber 
"  spring  "  tobacco  pouch,  where  the  distal  end  of  the  tube  presses 
against  the  mucosa  by  its  weight.  Ever  so  slightly  drawing 
the  penis  out  gives  this  region  a  funnel-lite  appearance,  leaving 
the  "  central  figure  "  somewhat  smaller,  and  differing  in  various 
parts  of  the  urethra.  Just  behind  the  glans  it  appears  as  a 
small  round  or  oval  opening,  deeper  within  the  urethra  it  looks 
like  a  closed  dimple,  and  at  the  bulb  its  lower  half  arches  for- 
ward. 

Tlie  Morgagnian  (7r?/23fe.— When  drawing  the  tube  out  of  the 
urethra  five  to  ten  little  shallow  depressions  fall  into  view,  most 
of  them  centrally  located  toward  the  upper  two-thirds  of  the 
canal.     These  are  the  openings  of  the  Morgagnian  crypts. 

The  megaloscopic  attachment  will  considerably  augment  the 
apparent  size  of  the  above-described  parts. 

The  Normal  Posterior  Urethra. 

The  ca-put  gallinaginis  {vera  montanum,  colliculus  seminalis) 
is  usually  first  seen  in  the  posterior  urethra.  It  is  about  the 
size  of  a  split  pea,  semiglobular  in  shape,  sometimes  flattened 
and  smooth,  sometimes  elevated  and  with  a  furrowed  surface. 
It  is  of  the  same  red  color  as  the  surrounding  mucous  mem- 


URETHROSCOPY*  197 

brane.  Depressions  suggesting  crypts  may  sometimes  be  seen 
about  it.  These  are  the  openings  of  the  prostatic  sinus,  and  of 
the  prostatic  and  ejaculatory  ducts. 

The  sinus  joocularis  {uterus  or  utriculus  m.asculinus)  opens  at 
the  anterior  declivity  of  the  caput  gallinaginis  as  a  fine  slit. 
It  is  a  little  sac,  of  a  lengthened  pear  shape,  which  passes  up- 
ward and  backward  to  the  base  of  the  prostate  and  ends  between 
the  ejaculatory  ducts.  It  may  be  materially  enlarged,  so  much 
so  as  to  catch  and  arrest  tlJe  progress  of  an  instrument  toward 
the  bladder,  if  the  instrument  is  not  guided  along  the  roof  of  the 
posterior  urethra. 

The  'posterior  urethral  funnel  is  very  short. 

The  lustre  of  the  posterior  urethral  mucosa  is  less  than  that 
lining  the  anterior  urethra. 

The  posterior  urethral  folds  are  so  shallow  as  often  to  convey 
the  impression  of  their  entire  obliteration. 

The  anterior  houndary  of  the  posterior  urethra  is  naturally  the 
posterior  boundary  of  the  anterior  urethra.  The  withdrawal  of 
the  tube  marks  it  clearly,  not  only  by  release  from  the  tight  grasp 
of  the  compressor  upon  the  tube,  but  also  by  the  appearance 
of  the  marked  folds  of  the  bulbous  portion. 

Bleeding  during  posterior  urethroscopy  is  not  at  all  infre- 
quent, especially  when  it  is  made  for  the  first  time. 

Ueethroscopic  Appearances. 

For  the  student's  convenience,  the  appearances  of  the  ure- 
thra are  here  alphabetically  arranged.  No  pretence  to  any- 
thing more  than  a  mere  introduction  to  the  study  of  urethro- 
scopic  diagnosis  is  made. 

Bleeding  in  the  posterior  urethra  occurs  more  readily  than  in 
health  from  mere  contact  with  the  tube  in  the  soft  infiltration  of 
chronic  posterior  urethritis. 

Bleeding  Sp)ots. — Where  epithelial  denudations  have  been 
followed  by  slight  granulations,  these  bleed  easily. 

Blood-vessels  not  visible  in  hard  infiltrations. 

Brilliancy  (see  Lustre). 

Caput  gallinaginis  pale,  yellowish  color,  lacks  lustre,  does 
not  project,  is  not  wrinkled,  but  is  flat  and  smooth  in  hard  in- 
filtration of  the  posterior  urethra. 


198         THE   IRRIGATION   TREATMENT   OF   GONORRHCEA, 

Central  figure  appears  as  a  wide,  often  distorted  passage  in 
liard  (dry)  infiltrations. 

Color,  dull  gray  in  hard  infiltrations. 

Cyanotic,  purplish  color  of  posterior  urethra  evidences  soft 
infiltration. 

Denudation,  epithelial,  in  advanced  inflammatory  processes 
and  in  superficial  traumatisms  of  the  mucosa. 

Desquamation,  epithelial,  distinct,  in  hard  infiltrations. 

Desquamation,  epithelial,  slight,  in  somewhat  advanced  in- 
flammation. * 

Dull,  dry  epithelium  with  lack-lustre  appearance,  indicates 
subepithelial  inflammation  of  the  glands.  Their  orifices  are 
then  not  visible. 

Dull,  uneven  mucosa,  when  in  the  first  stage  of  inflammation 
the  cellular  infiltration  is  denser  than  ordinarily. 

Epithelial  denudation,  in  advanced  inflammatory  processes. 

Epithelium  desquamating  (see  Desquamation,  epithelial,  dis- 
tinct and  slight). 

Folds  absent  in  hard,  dry  infiltrations. 

Folds  grosser,  thicker,  coarser,  broader  and  from  four  to 
six  in  number  instead  of  from  eight  to  twelve,  in  more  dense 
cellular  infitration  than  usual  in  the  early  stage  of  inflamma- 
tion. 

Gaping  Glands. — The  orifices  of  Littre's  glands  and  of  the 
Morgagnian  crypts  gape  and  are  surrounded  by  a  puffy,  red, 
prominent  wall,  forming  a  distinct  boundary  from  the  healthy 
tissues,  in  the  more  severe  forms  of  chronic  gonorrhoea,  with 
consequent  infiltration  around  the  crypts.  Occasionally  some 
secretion  oozes  from  the  orifices  in  this  stage  of  urethritis 
mucosae  or  soft  infiltration. 

Glands  and  crypts  are  always  visible  in  first  degree  of  hard 
infiltration  as  red  inflamed  spots. 

Glands  and  crypts  are  not  visible,  or  but  very  few  appear,  in 
the  second  variety  of  infiltration  (dry  infiltration),  as  their 
orifices  are  covered  by  epithelia  and  connective  tissue. 

Glandular  Orifices.— More  are  visible  than  in  health,  when 
the  mucosa  is  diseased.  When  the  epithelial  layer  of  the  mu- 
cosa is  destroyed,  then  the  more  deeply  the  mucosa  is  invaded, 
the  greater  is  the  exposed  part  of  the  glands.  They  appear 
as  minute  red  specks,  mostly  in  groups.     When  the  megalo- 


URETHROSCOPY.  199 

scope  is  used,  the  glandular  form  and  ducts  are  made  plainly 
visible. 

Granulations  appear  on  spots  that  have  been  denuded  of 
their  epithelium.  They  often  bleed  readily  at  contact  with  the 
margin  of  the  tube. 

Gray  Color. — In  hard,  dry  infiltrations  the  mucosa  has  a 
gray  color. 

Grayish  ojjaque  veil  covers  mucosa  in  hard  infiltrations. 

Hard  injiltration  is  rare  in  the  posterior  urethra. 

Hard  infiltration  is  the  outcome  of  transformation  of  cellular 
into  fibrous  infiltration.  Its  urethroscopic  manifestations  nat- 
urally vary  as  this  transformation  progresses. 

Hillochy  mucosa  is  sometimes  seen  in  hard  infiltrations. 
The  mucosa  has  lost  its  brilliancy  and  may  distinctly  des- 
quamate. 

Injiltration,  hard,  rare  in  posterior  urethra. 

Injiltration,  soft,  frequent  in  chronic  posterior  urethritis. 

Littres  glands  are  grouped  about  the  Morgagnian  crypts. 
They  are  ordinarily  not  visible  in  health.  The  experienced 
urethroscopist,  however,  employing  the  megaloscope,  in  many 
cases  can  see  the  mouths  of  the  normal  Littre's  glands  and  even 
part  of  their  ducts  as  they  descend  beneath  the  epithelium  of 
the  mucosa.  The  mouths  of  these  glands  may  remain  visible  a 
long  time  after  the  urethra  has  returned  to  health.  They  may 
also  be  invisible  in  disease,  if  the  pathological  process  occurs 
subepithelially.  The  form  of  disease  affecting  these  glands, 
whether  visible  or  not,  shows  its  results  upon  the  Morgagnian 
<3rypts. 

Small  red  points  are  the  mouths  of  Littre's  glands  in  simple 
swelling. 

Large  red  points,  projecting  into  the  urethra,  show  that 
Littre's  glands  are  in  a  state  of  infiltrative  inflammation.  The 
fibrillary  connective  tissue,  always  present  in  chronic  gonor- 
rhoea, is  then  formed  about  the  ducts  and  bodies  of  Littre's 
glands.  This  fibrillary  connective  tissue  is  caused  by  the  finely 
granular  infiltration  of  the  acute  inflammation. 

Littre's  glands  are  not  visible  in  the  dry  form  of  hard  infiltra- 
tions. In  this  condition  the  epithelium  looks  dull  (lack-lustre) 
and  dry,  and  desquamates  in  spots. 

Lustre    apparently  increased    by  liquid   (glycerin,  cocaine, 


200  THE   IRRIGATION   TREATMENT   OF   GONORRHOEA. 

mucus,  urine)  left  on  mucous  lining.  To  jjrevent  error,  the 
surgeon  should  attempt  to  remove  the  excessive  lustre  by  care- 
ful use  of  absorbent  cotton  attached  to  applicators. 

Lustre  decreased  with  increased  infiltration  and  in  epithelial 
desquamation,  with  or  without  infiltration.  The  brilliancy  is 
entirely  lost  in  hard  infiltrations. 

Lustre  gone  in  epithelium  covering  glandular  orifices,  with 
dull,  dry  appearance  of  mucosa,  indicates  subepithelial  inflam- 
mation of  the  glands. 

Lustre  increased  in  subacute  superficial  urethritis.  The  mu- 
cosa is  congested  and  swollen  from  cellular  infiltration. 

Lustre  of  posterior  urethra  increased  in  soft  infiltration. 

The  Morgagnian  crypts  are  visible  in  all  chronic  diseases  of 
the  urethra,  and  are  modified  according  to  the  intensity  of  the 
disease  of  Littre's  glands.  The  mouth  of  a  crypt  is  larger  than 
those  of  the  surrounding  Littre's  glands,  often  appearing  as  a 
quite  evident  dark-red  slit.  The  variations  from  simple  swell- 
ing to  infiltrative  inflammation  are  similar  to  those  which  take 
place  in  Littre's  glands.  When  the  megaloscope  is  used,  and 
slight  pressure  made  upon  an  opening  of  a  crypt  by  bending 
the  urethra,  pus  may  be  seen  welling  from  the  red  slit.  Its 
patency  ("  gaping  ")  will  then  become  more  evident  and  show 
that  it  is  not  a  tear  in  the  urethra,  but  really  a  widely  open 
emunctory  duct. 

Neoplasms.— The  most  frequent  tumors  of  the  urethra  are 
papillomata  and  fibrous  polypi.  Carcinoma  of  the  urethra  is 
very  rare.  Before  Oberlaender  diagnosed  a  primary  carcinoma 
of  the  urethra  in  1893,  the  disease  was  only  accidentally  dis- 
covered in  its  advanced  stages  during  an  operation.  Ober- 
laender's  early  discovery  of  this  carcinoma  enabled  the  patient 
to  be  operated  upon  promptly.  A  year  later  no  evidence  of  the 
disease  had  recurred. 

Opaque  grayish  veil  covers  mucosa  in  severer  forms  of  in- 
filtration. 

Posterior  urethroscopy  is  not  j^ermissible  in  acute  or  sub- 
acute posterior  urethritis,  in  tuberculosis,  or  in  acute  prosta- 
titis. 

Prominence,  reddish,  within  the  mucosa,  with  a  central 
dimple  and  invisible  lumen,  is  seen  when  the  inflammation  has 
become  follicular.     The  finger  can  feel  these  encapsulated  crypts 


URETHROSCOPY.  201 

as  small   hard  nodules.      Their  breaking  down  may  produce 
peri-uretliral  abscess. 

Psoriasis  mucosce  uretliralis  (Oberlaender) — see  White  Patches. 

Purple  color,  of  posterior  urethra — see  Cyanotic  Color. 

Red  specl's  with  swollen,  puffy  surroundings,  occasionally 
exuding  a  watery,  milky,  or  purulent  discharge,  show  in-, 
flammation  of  the  Morgagnian  crj^pts.  See  also  Glandular 
Orifices. 

Resistance  to  urethroscopic  tube  as  it  is  being  introduced  is 
felt  in  hard  infiltrations. 

Rigid  Urethra.  — The  denser  the  fibrous  tissue  in  dry,  hard 
infiltration,  the  more  rigid  does  the  urethra  become ;  in  its  fully 
developed  form  it  shows  white  cicatricial  tissue,  spotted  with 
groups  of  red  orifices  of  Littre's  glands. 

Seedy  and  uneven  epithelial  layer  in  severe  infiltrations. 

Smoothness  of  epithelium  lost  in  severer  forms  of  infiltration 
of  the  mucosa. 

Specks,  red — see  Glandular  Orifices. 

Specks,  lohite—see  White  Patches. 

Stria,  almost  or  quite  obliterated  in  dense  cellular  infiltra- 
tions ;  no  vestige  of  them  remains  in  hard,  dry  infiltration.  In 
some  normal  urethras  the  striae  are  absent. 

Sivelling  of  mucosa  of  posterior  urethra  in  soft  infiltration. 

Transparency  lost  in  hard  infiltrations. 

Tumors — see  Neoplasms. 

Ulcerations  due  to  epithelial  denudations  of  inflammatory 
origin  are  usually  longitudinal.  They  may  result  from  trauma- 
tism produced  by  excessive  or  violent  dilatation.  Ulceration  of 
a  circular  tendency  may  be  chancre  or  chancroid. 

Uneven  and  dull  mucosa  in  denser  cellular  infiltration,  at  the 
first  stage  of  inflammation. 

Uneven  and  seedy  epithelial  layer,  in  severe  infiltration. 

Veil. — A  thin  veil  seems  to  cover  the  urethra  in  hard  infiltra- 
tion ;  in  spots  elevated  scales  present.     These  gradually  heal. 

TVJiite  patches,  irregular  in  shape  from  small  specks  to  large 
patches,  called  "psoriasis  mucosae  urethralis  "  by  Oberlaender. 
Kollmann  found  these  psoriatic  pellicles  to  consist  of  cumuli  of 
firmly  agglutinated  epithelial  cells,  whose  nuclei  stained  dis- 
tinctly with  Bismarck  brown.  These  epithelia  were  of  polygonal 
pavement  shape,  rounded  epithelia,  and  some  high  cylindrical 


■202 


THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 


epithelia  as  are  found  in  the  prostate.      The  course  of  this 
psoriasis  is  very  chronic. 

Note  :  This  chapter  is  elaborated  from  the  report  of  my  first 
public  demonstration,  in  the  Journal  of  Cutaneous  and  Genito- 
urinary Diseases  for  April,  1899,  and  from  my  article  in  the 
Journal  of  the  American  Medical  Association  for  September  7th, 
1899. 


XIV.  THE  PHOOFS  OF  CURE  OF  GONORRHCEA. 

To  secure  a  patient  who  no  longer  presents  any  tangible 
evidences  of  gonorrhoea  against  auto-reinfection  and  possible 
infection  of  others,  no  case  should  be  dismissed  from  treatment 
until  all  the  tests  at  present  known  have  resulted  negatively  in 
his  case. 


Fig.  57.— Stripping  Uretlira. 

While  most  of  these  have  been  mentioned  incidental  to 
other  matters,  all  are  here  placed  together  for  the  practitioner's 
convenience.  In  describing  them,  a  note  is  added  to  each  test 
of  the  errors  that  may  thwart  its  purpose. 

Stripping  the  t^ref/ira. —Patients,  especially  those  anxious  to 


THE  PROOFS  OF  CURE  OF  GONORRHCEA.       203 

demonstrate  that  they  have  recovered,  squeeze  the  penis,  some- 
times quite  violently,  to  prove  the  absence  of  a  discharge.  The 
conformation  of  the  organ  renders  this  method  futile  in  bring- 
ing to  view  any  evidence  of  disease,  even  when  the  urethra  has 
an  appreciable  quantity  that  can  be  produced  with  the  proper 
technique,  as  follows : 

1.  Eest  the  four  left  fingers  upon  the  outer  side  of  the  left 
corpus  cavernosum,  and  the  left  thumb  upon  the  opposite  side, 
thus  endeavoring  to  approximate  the  corpora  cavernosa  to  each 
other  and  exercising  a  pressure,  as  if  to  squeeze  the  urethra 
from  between  them. 

2.  With  the  bent  right  index  finger  press  the  peno-scrotal 
angle  backward  as  far  as  possible  to  the  lower  margin  of  the 
pubic  arch.  Firmly  pressing  the  so  bent  finger  upward  and 
carrying  this  pressure  steadily  forward,  any  moisture  thus  ob- 
tainable will  be  brought  to  the  meatus.  It  is  not  at  all  rare  that 
a,  large  yellow,  purulent  drop  replete  with  gonococci  can  be  so 
stripped  from  the  urethra  long  after  all  discharge  has  ceased. 

A  great  many  patients,  as  anxious  as  the  first  mentioned, 
but  in  the  opposite  direction — namely,  to  prove  that  they  are  not 
cured — acquire  remarkable  dexterity  in  maintaining  an  urethror- 
xhoea  by  frequent  strijDpings  of  the  urethra.  These  can,  at  al- 
most all  times,  produce  a  transparent  or  translucent  drop  at  the 
meatus.  Its  microscopical  examination  reveals  mucus,  urethral 
«pithelia,  and  occasionally  some  leucocytes. 

In  either  case,  urethroscopic  examination  is  required  to  de- 
termine the  region  or  gland  whence  the  drop  comes,  or  to  elicit, 
in  the  second  category  of  cases,  whether  the  drop  the  patient 
milks  from  his  urethra  is  due  to  general  excessive  juiciness  of 
the  canal.  In  the  former  the  treatment  mentioned  in  Chapter 
IX.  is  applicable.  But  a  patient  who  maintains  the  irritability 
of  his  urethra  by  continual  milkings  is  more  difiicult  to  manage. 
Arguments  and  persuasion  are  ordinarily  of  little  avail;  the 
conviction  that  he  is  incurable  is  usually  deep-rooted  in  his 
mind,  and  is  reinforced  by  each  milking,  wherein  he  persists 
until  the  convincing  drop  is  brought  forth.  A  good  method  for 
the  treatment  of  such  cases  is  to  irrigate  the  urethra  with  four- 
per-cent.  boric-acid  solution  and  to  order  the  patient,  with  a  view 
to  diverting  his  attention  from  persistent  milkings,  to  inject  a 
drachm  or  two  of  the  same  solution  several  times  daily,  if  he 


204:         THE   IRRIGATION   TREATMENT   OP   GONORRHCEA. 

cannot  be  otherwise  dissuaded  from  the  milking  liabit.  One 
case,  after  all  else  had  failed,  was  cured  by  the  cruelty  of  paint- 
ing the  lower  half  of  his  penis  with  cantharidal  collodion.  The  re- 
sultant blisters  prevented  his  handling  the  organ  for  two  weeks ; 
then  they  were  permitted  to  heal.  He  did  not  resume  the  milk- 
ings,  but  persists  in  the  firm  belief  that  the  blistering  cured  him. 

Possible  Errors.- — Stripping  the  urethra  may  fail  to  produce  a 
drop  or  an  excess  of  moisture  from  a  diseased  anterior  urethra,  if 
the  patient  has  urinated  within  a  few  hours.  In  many  cases  it  can- 
not be  made  evident  at  all,  unless  the  examination  is  made  in  the 
morning,  if  the  patient  has  not  urinated  since  the  night  before. 

If  the  drop  cannot  be  stripped  out  during  the  da}-,  and  if  for 
any  reason  the  patient  cannot  be  examined  while  his  bladder 
holds  the  night's  urine,  the  patient  should  be  given  several 
cover-glasses  and  be  instructed  to  catch  a  small  quantity  of  the 
morning  drop  upon  one  and  press  another  cover-glass  upon  it. 
Thus  the  drop  can  be  brought  to  the  office  for  microscopical  ex- 
amination. The  fact  that  one  specimen  is  found  to  be  free  froin 
gonococci  does  not  prove  their  absence.  It  will  always  be  best 
to  make  ten  such  examinations,  two  or  three  days  apart,  before 
finally  concluding  that  the  morning  drop  contains  no  bacteria. 
Even  then  it  is  by  no  means  safe  to  declare  the  patient  unable 
to  infect  others  or  to  reinfect  himself.  Gonococci  may  be  resid- 
ual in  some  part  of  the  urethra,  and  by  their  presence  pro- 
voke the  non-bacterial  drop.  Therefore  this  test  cannot  be 
accepted  as  final,  nor  can  the  case  be  pronounced  cured,  until 
all  the  tests  here  recited  have  proven  the  absence  of  gonococci 
and  the  healthy  condition  of  the  urethra  and  its  adnexa. 

The  Urine. — AVhenever  possible,  examination  of  the  urine 
for  evidences  of  urethral  disease  should  be  made  before  the 
patient  has  jjassed  any  part  of  his  night's  accumulation  in  the 
bladder.  Ordinarily'  it  is  assumed  that  the  first  50  c.c.  passed 
in  the  morning  suffice  to  wash  out  the  anterior  urethra.  This 
quantity,  however,  does  not  seem  sufficient  in  all  cases.  There- 
fore it  is  best  always  to  have  the  patient  j)ass  first  150  c.c.  into  a. 
tube  as  directed  (on  page  25)  in  Chapter  IV. ,  and  to  pursue  the 
other  steps  there  directed. 

Possible  Errors. — On  centrifuging  clear  urine,  a  deposit  ma^ 

'Posner:  Diagnostik  der  Harnkrankheiten,  Berlin,  1895. 


THE  PROOFS  OF  CURE  OF  GOXORRHCEA.       205 

be  obtained.  If  not,  a  few  drops  of  alcohol  added  to  the  speci- 
men will,  on  second  centrifuging,  throw  down  a  slight  deposit. 
In  case  this  deposit,  microscopically  examined,  shows  thinned 
epithelium  with  very  faint  nuclei  or  none,  the  patient  should 
be  warned  that  an  infiltration  is  at  least  beginning,  and  that  he 
naust  be  at  once  treated  by  dilatations  lest  he  become  a  victim 
of  stricture  and  all  it  portends. 

Filaments,  flakes,  etc.,  have  been  discussed  in  other  parts  of 
this  book  (see  page  144). 

Ramonacje. — The  great  master  Guy  on  suggests  this  method 
of  obtaining  specimens  from  the  deeper  urethra  for  microscopic 
examinations.  It  consists  in  anointing  with  glycerin  as  large  a 
bougie-a-boule  as  can  be  easily  introduced.  Immediately  upon 
its  withdrawal  from  the  urethra,  the  substances  that  adhere, 
especially  to  its  shoulder,  are  removed  for  examination. 

This  bougie  may,  however,  fail  to  bring  with  it  any  patho- 
logical products.  Owing  to  a  possible  excess  of  glycerin  or  an 
over-juicy  urethra,  evidences  of  disease  may  be  swept  from  the 
bougie  before  it  is  entirely  withdrawn.  Still,  in  the  majority 
of  cases  it  will  be  well  to  examine  the  substances  adhering  to 
the  bougie,  even  when  the  purpose  of  its  use  was  only  to  search 
for  infiltrations,  stricture,  etc. 

Scraping  the  urethra  is  performed  by  holding  a  platinum 
loop  in  the  alcohol  or  Bunsen  flame  until  it  is  red  hot,  and, 
while  not  permitting  its  sterility  so  obtained  to  be  impaired 
by  contact  with  anything,  to  allow  it  to  cool.  Then,  holding 
the  penis  as  for  stripping  {vide  Fig.  57)  the  cooled  loop  is  gently 
passed  into  the  urethra.  As  it  is  drawn  out  it  is  pressed  against 
the  urethral  walls  sufficiently  to  detach  some  of  the  adherent 
contents.  They  will  at  least  fill  the  eye  of  the  loop.  Striking 
it  upon  a  slide  or  upon  a  cover-glass  furnishes  a  specimen  for 
microscopical  examination. 

After  each  such  scraping  the  loop  must  be  thoroughly  re- 
sterilized  by  flaming,  lest  by  it  the  next  case  so  examined  be  in- 
fected, or,  at  least,  the  specimen  taken  from  him  be  vitiated. 

Swabbing  the  Urethra. — When  the  urethral  excess  is  too 
minute  to  be  obtained  by  ramonage  or  scraping,  sufficient  moist- 
ure can  be  swabbed  therefrom  for  examination.  The  swab  is 
made  by  tightly  wrapping  a  small  quantity  of  borated  cotton 
upon  a  sterilized  platinum  loop ;  then  lighting  the  cotton  in  the 


206         THE   IRRIGATION  TREATMENT    OF   GONORRHCEA 

flame  and  instantly  blowing  it  out.  A  light  rap  with  the  handle 
of  the  loop  upon  a  finger  will  cause  the  charred  parts  of  the 
cotton  to  drop  off.  This  swab  may  then  be  used  without  a 
lubricant  to  obtain  a  specimen.  Its  employment  is  naturally 
limited  to  the  anterior  third  or  half  of  the  urethra. 

Residual  Posterior  Gonorrhoea — see  Chapters  IV.,  VIII., 
and  X. 

Expression  Urine. — The  patient  is  laid  upon  a  table  and  the 
index  finger,  prepared  as  directed  in  Chapter  XI.,  is  well  an- 
ointed and  inserted  into  the  rectum.  Avoiding  the  prostate, 
the  pulp  of  the  finger  presses  upon  the  posterior  urethra  by 
stroking  it  firmly  from  above  downward  against  the  j)ubis. 
The  urine  accumulating  during  this  process  will  contain  as 
much  evidence  of  posterior  urethral  disease  as  can  be  detached 
by  this  method. 

Infection  of  the  Prostate,  Seminal  Vesicles,  or  Cowper's  Glands. 
— Stripping  these  adnexafor  the  purpose  of  obtaining  specimens 
therefrom  is  described  in  Chapter  XI. 

Possible  Errors. — No  attempt  should  be  made  to  obtain  speci- 
mens from  the  posterior  urethra  or  the  prostate,  seminal  vesi- 
cles, or  Cowper's  glands,  at  the  same  examination,  lest  their 
contents  intermingle  in  the  urethra  and  thus  give  no  positive 
indications  regarding  the  region  infected. 

Beer  Test. — ^A  week  after  all  evidence  of  gonorrhoea  haa 
ceased  the  patient  is  ordered  to  drink,  in  the  evening,  double 
the  quantity  of  beer  or  champagne  he  was  in  the  habit  of  con- 
suming before  they  were  forbidden  him.  This  may,  within 
twelve  to  thirty-six  hours,  produce  a  discharge,  if  any  disturb- 
ance exists..  Microscopical  examination  of  the  discharge  will 
decide  its  character. 

Silver  and  Bichloride  Tests. — 'When  the  beer-test  fails  to  pro- 
duce a  discharge,  an  irritant  irrigation  of  the  anterior  urethra 
with  silver  nitrate  one  per  cent,  or  corrosive  sublimate  1 : 5,000 
will  evoke  one,  lasting  from  eight  to  thirty-six  hours.  If  the 
discharge  so  established  contains  gonococci,  they  most  probably 
but  not  positively  are  located  in  the  anterior  urethra. 

Condom  Test. — The  other  tests  having  resulted  negatively, 
the  patient  is  advised  to  use  a  condom  at  his  next  sexual  inter- 
course and  to  bring  it  with  its  contents  for  microscopical  ex- 
amination.    It  is  most  likely  to  contain,  in  addition  to  semen. 


THE   PEOOFS   OF   CURE    OF   GONORRHCEA.  20T 

some  of  tlie  contents  of  tlie  uretliral  mucosa  and  its  glands,  as 
well  as  any  bacteria  the  reproductive  apparatus  may  harbor. 
The  various  local  tests  suggested  must  then  be  employed  to  de- 
termine the  region  in  which  the  bacteria  are  held. 

It  would  go  beyond  the  province  of  this  effort  to  discuss  the 
morality  of  advising  a  patient  to  cohabit  or  to  use  a  condom. 
The  majority  during  the  acuity  of  their  sufferings  invariably 
forswear  sexual  relations  during  the  remainder  of  their  lives. 
As  a  rule,  the  more  vehement  their  asseverations  in  this  regard 
the  sooner  will  they  again  seek  sexual  gratification,  often  during 
the  period  when  it  is  still  positively  forbidden.  With  or  with- 
out permission,  when  evidences  of  the  disease  have  passed  and 
the  tests  before  mentioned  have  yielded  negative  results,  these 
patients  will  have  coitus.  Is  it  not  best  to  avail  one's  self  of  their 
immorality  for  their  own  good  and  the  protection  of  their  pro- 
spective wives  by  asking  for  a  condom  specimen? 

When  even  the  condom  test  has  proven  negative  or  when  the 
physician's  conscientious  scruples  cause  its  omission  the  final 
resort  is 

Tlie  Urethroscope  (see  Chapter  XIII.). — If  a  healthy  urethra 
is  found,  and  its  adnexa  are  proven  to  be  normal,  the  case  may 
be  discharged. 

Preparation  of  a  Specimen  for  31ici'oscoiyical  Examination. — 
For  the  convenience  of  those  not  rendered  familiar  with  the  tech- 
nique, by  daily  examination  for  gonococci,  the  method  that  is 
easiest  and  most  reliable  is  here  recapitulated : 

1.  Spread  as  thinly  as  possible  upon  a  cleaned  cover-glass 
the  discharge,  drop,  filament,  urinary  sediment,  or  specimen 
taken  with  a  sterilized  platinum  needle  from  the  contents  of  a 
condom. 

2.  Let  the  specimen  dry  under  a  bell-glass,  to  protect  it 
from  dust  or  air  microbes.  This  usually  requires  about  three 
minutes. 

3.  Pass  it  three  times  through  the  opened  Bunsen  flame, 
with  an  even  motion,  to  "  fix  "  it. 

4.  Dropeosin  (saturated  solution  in  alcohol)  upon  the  cover- 
glass  and  hold  it  over  the  closed  Bunsen  jet  until  a  slight, 
visible  evaporation  results. 

5.  Hold  it  under  a  stream  of  water  until  all  the  eosin  that 
can  be  washed  away  is  carried  off.     If  the  cover-glass  stood  on. 


208         THE   IRRIGATION   TREATMENT   OF   GOXORRHCEA. 

edge  over  filter  paper  gives  the  paper  ever  so  slight  a  tinge,  the 
washing  has  been  insufficient,  and  must  be  repeated  until  noth- 
ing ,but  clear  water  comes  from  the  glass. 

6.  Drop  two  per  cent,  methylene  blue  upon  the  glass  and  let 
it  rest  there,  covered,  for  five  minutes. 

7.  Wash  as  described  under  5,  let  it  dry,  and  then  mount  it 
for  examination. 

8.  Unstain  by  the  Gram  method. 

Physicians  who  cannot  devote  the  ten  or  twelve  minutes  to 
this  preparation  of  a  slide  will  do  well  merely  to  take  the  speci- 
men on  a  cover-glass,  place  another  cover-glass  upon  it,  and 
send  the  specimen  to  a  colleague  or  a  bacteriological  laboratory, 
for  examination. 

For  positive  assurance  culture  experiments  are  necessary. 
These,  however,  cannot  be  made  save  hy  a  physician  provided 
with  a  laboratory  fitted  for  the  purpose. 


XV.    THE   MARRIAGE   OF   GONORRHCEICS. 

The  question  that  most  frequently  confronts  the  general 
practitioner,  as  well  as  the  specialist,  concerns  the  marriage  of 
those  who  have  had  gonorrhoea,  and  the  resumption  of  matri- 
monial relations  by  married  infractors  who  acquired  the  disease 
extra  domo. 

Advice  in  this  regard  cannot  be  lightly  given.  In  support 
liereof  a  slight  historical  digression  may  be  permitted. 

E.  Noeggerath,'  of  New  York,  in  1872  asserted,  as  Ricord 
had  before  him,  that  eight  hundred  men  of  every  one  thousand 
living  in  large  cities  had  gonorrhcea.  The  recently  deceased 
eminent  gynecological  surgeon,  Mr.  Lawson  Tait,  went  further 
in  this,  claiming  that  every  man  at  least  once  during  his  life 
acquired  clap.  ^\Tiile  obser^'ation  and  experience  compel  ac- 
ceptance of  Tait's  estimate  as  nearer  the  facts,  the  author  can 
positively  assert  that  at  least  one  man,  now  almost  fifty  years 
of  age,  has  not  been  so  unfortunate. 

Noeggerath,  in  the  same  dissertation,  and  in  the  light  of 
the  treatment  then  employed,  asserted  that  men  infected  with 

'  Noeggeratli ;  Die  latente  Gonorrhoe  im  weiblichen  Geschlecht,  Bonn, 
1872. 


THE   MARRIAGE    OF   GONORRHCEICS.  209 

gonorrhoea  never  recovered.  He  further  insisted  that  ninety  per 
cent,  of  these  men,  when  they  married,  infected  their  wives. 
The  eminent  surgeon's  views  were  fiercely  combated,  yet 
stanch  in  his  convictions  he,  four  years  later,  summarized  his 
conclusions  in  a  paper  on  the  subject,'  as  follows : 

"1.  Gonorrhoea  in  the  male,  as  well  as  in  the  female,  per- 
sists for  life  in  certain  sections  of  the  organs  of  generation,  not- 
withstanding its  apparent  cure  in  a  great  many  instances. 

"2.  There  is  a  form  of  gonorrhoea,  which  may  be  called 
latent  gonorrhoea,  in  the  male  as  well  as  in  the  female. 

"  3.  Latent  gonorrhoea  in  the  male,  as  well  as  in  the  female, 
may  infect  a  healthy  person  either  with  acute  gonorrhoea  or 
gleet. 

"  4.  Latent  gonorrhoea  in  the  female,  either  the  consequence 
of  an  acute  gonorrhoeal  invasion  or  not,  if  it  pass  from  the  latent 
into  the  apparent  condition,  manifests  itself  as  acute,  chronic, 
recurrent  perimetritis  or  ovaritis,  or  as  catarrh  of  certain  sections 
of  the  genital  organs. 

"5.  Latent  gonorrhoea,  on  becoming  apparent  in  the  male, 
does  so  by  attack  of  gleet  or  epididymitis. 

"  6.  About  ninety  per  cent,  of  sterile  women  are  married  to 
husbands  who  have  suffered  from  gonorrhoea,  either  previous  to 
or  during  married  life." 

Noeggerath's  conclusions  were  based  purely  upon  clinical 
experience.  They  were  in  no  wise  essentially  controverted 
Avhen  three  years  later  Neisser^  published  his  epoch-making 
discovery  of  the  gonococcus. 

If  Noeggerath's  note  of  alarm  needs  further  confirmation  it 
is  found  in  the  statistics  of  the  German  empire  for  1894.  These 
show  that  of  the  women  who  died  of  diseases  of  the  womb,  or 
of  its  adnexa,  eighty  per  cent,  were  proven  to  have  succumbed 
to  gonorrhoeal  infection.  They  further  show  that  of  all  chil- 
dren who  became  hopelessly  blind  after  having  been  born  with 
healthy  eyes,  eighty  per  cent,  went  into  a  life  of  darkness  from 
gonorrhoea.  Since  1894,  the  Crede  method  of  swabbing  the 
eyes  of  the  new-born  with  two-per-cent.  silver-nitrate  solution 

'  Noeggerath  :  "Latent  GonorrhcEa  in  the  Female."  Transactions  of  the 
American  Gynecological  Society,  1876. 

'Neisser:  "Eine  der  Gonorrhoe  eigenthiimliche  Mikrokokkenform." 
Centralblatt  fiir  medicinische  Wissenschaften,  No.  28.  1879. 

14 


210  THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

lias  saved  many  eyes.  And  since  the  irrigation  treatment  and 
a  clearer  understanding  of  the  dangers  of  gonorrhoea  have  be- 
come more  generalized,  doubtless  many  women  are  saved  from 
infection. 

It  cannot  for  a  moment  be  assumed  that  the  men  who  caused 
the  death  of  their  wives  or  the  blindness  of  their  children  mar- 
ried with  the  knowledge  that  they  could  produce  such  disastrous 
results.  If  there  is  one  among  the  thousands  who  did  so,  no 
punishment  known  to  any  modern  criminal  code  could  ade- 
quately expiate  his  iniquity.  With  the  ever-increasing  atten- 
tion given  by  the  profession  to  the  appreciation  of  the  dangers 
of  gonorrhoea,  it  is  to  be  hoped  that  this  menace  to  human  hap- 
piness will  be  eventually  stamped  out. 

It  is  perfectly  true  that  many  men  to-day,  uninformed  of  the 
seriousness  of  clap,  boast  of  having  had  innumerable  attacks  of 
the  disease  and  of  having  relieved  themselves  therefrom  by 
trifling  medication  or  advertised  nostrums.  It  is  exceedingly 
interesting  to  note  that  none  of  these  boasts  are  made  while  the 
patient  has  gonorrhoea,  and  that  he  does  not  employ  the  vaunted 
preparations  when  he  acquires  a  new  attack. 

The  physicians  and  those  of  the  public  who  make  clap  a 
subject  of  witticism  are  not  without  their  influence  upon  the 
people  in  general.  All  men,  however,  when  they  have  gonor- 
rhoea, know  that  it  was  contracted  from  a  woman,  and  it  would 
be  the  extreme  of  pessimism  to  assert  that  a  man,  knowing  that 
he  can  infect  a  woman,  would  marry.  Still,  it  is  difiicult  to 
convince  such  a  man,  after  he  perceives  no  evidence  of  the  dis- 
ease, that  the  danger  of  infecting  his  future  wife  may  continue. 
For  such  it  will  be  well  to  cite  a  typical  case,  couched  in  lan- 
guage within  the  reach  of  his  intelligence. 

Five,  ten,  or  more  years  after  a  man  had  gonorrhoea,  time 
has  almost  if  not  entirely  effaced  the  disagreeable  incident  from 
his  recollection.  He  marries  a  girl,  strong  and  healthy.  The 
young  wife  soon  begins  to  fade.  Vague  pains  set  in.  If  her 
friends  love  her,  she  will  be  twitted  with  advice  and  congratula- 
tions regarding  the  presumed  coming  maternit}'.  Her  form, 
too,  suggests  such  possibilit3^  But  by  the  time,  or  before,  the 
child  that  is  to  make  her  still  more  loved  by  her  husband  is  ex- 
pected, it  is  found  necessary  to  seek  professional  advice. 

A  cyst  of  the  ovary,  a  Fallopian  tube  filled  with  pus,  or 


THE   MARRIAGE   OF   GONORRHCEICS.  211 

some  other  dangerous  disease  is  discovered.  An  operation, 
perilous  to  life,  must  be  performed  to  save  her.  If  she  survive, 
she  will  no  longer  be  a  woman,  for  she  cannot  become  a  mother. 
The  light  of  modern  microscopy  brought  to  bear  upon  the 
tumor,  cyst,  or  other  substance  removed  reveals  gonococci. 
Eemember  that  this  wreck,  but  a  few  short  months  ago  a  vigor- 
ous, healthy  girl,  was  "as  chaste  as  ice,  as  pure  as  snow." 
Eemember,  too,  that  her  husband  presented  no  sensory  evidence 
of  the  disease  that  killed  his  cherished  wife.  Killed — the  word 
is  advisedly  employed — for,  though  she  live,  she  is  worse  than 
dead;  she  is  not  only  unsexed,  but  also  physically  and  often 
mentally  destroyed. 

If  a  patient  is  morally  so  debased  that  such  an  argument 
does  not  appeal  to  him,  he  should  be  made  to  understand  what 
at  least  some  of  the  complications  and  sequelae  of  gonorrhoea 
portend  to  him.  He  will  listen  to  the  fact  that  gonorrhoeal  pus 
in  ever  so  minute  a  quantity  entering  the  conjunctivae  can  irre- 
mediably destroy  his  sight  within  twenty-four  hours.  Equally 
will  he  appreciate  that  his  testicles  can  be  invaded,  rendering 
him  impotent  to  further  disseminate  the  disease.  Little  as  he 
may  care  for  the  lives  of  others,  he  can  be  made  to  understand 
that  even  long  after  he  observes  any  evidence  of  disease,  he  may 
die  from  the  consequences  of  gonorrhoea. 

All  these  facts,  impressed  upon  such  a  man,  will  induce  him 
to  submit  to  the  tests  tl^at  will  prove  whether  he  is  cured  (Chap- 
ter XIV. )  and  to  seek  treatment  for  the  ailment,  if  it  is  discov- 
ered that  he  still  carries  the  death-dealing  microbes. 

Ignorance  of  the  dangers  of  gonorrhoea  is  not  limited  to  the 
mentally  uncultured.  The  highest  literary  universities  in  our 
land  do  not  teach  their  students  even  the  veriest  rudiments  of 
genital  physiology  and  pathology.  The  editor  of  one  of  our 
foremost  American  magazines,  a  man  of  wide  general  scientific 
attainments,  expressed  surprise  when  informed  of  the  origin, 
prevalence,  and  dangers  of  gonorrhoea. 

The  task  of  instructing  and  warning  the  public  regarding 
the  dangers  of  this  ever-prevalent  disease  is  left  almost  wholly 
to  the  medical  profession.  But  such  teaching  can  appeal  only 
to  those  whose  intelligence  is  of  a  grade  sufiicient  to  grasp  its 
importance.     Others  can  be  reached  only  by  the  law. 

All  honor  must  be  tributed  to  the  legislators  of  Michigan, 


212         THE   IRRIGATION   TREATMENT   OF   GONORRHCEA. 

who  in  their  session  of  1899  '  enacted  that :  "  Any  person  who 
has  been  afflicted  with  syphilis  or  gonorrhoea,  and  has  not  been 
cured  of  the  same,  who  shall  marry  shall  be  deemed  guilty  of  a 
felony,  and  upon  conviction  thereof  in  any  court  of  competent 
jurisdiction  shall  be  punished  by  a  fine  of  not  less  than  five 
hundred  dollars  or  more  than  one  thousand  dollars,  or  by  im- 
prisonment in  the  state's  prison  at  Jackson  not  more  than  five 
years,  or  by  both  such  fine  and  imprisonment  in  the  discretion 
of  the  court," 

While  an  adulterer  or  anadultress  might  by  perjury  succeed 
in  throwing  the  odium  of  this  law  upon  an  innocent  party,  the 
fact  remains  that  Michigan  stands  in  the  front  of  the  world  in 
recognizing  the  dangers  of  uncured  syphilis  and  gonorrhoea. 
Naturally  this  enactment  must  have  been  prompted  by  the  phy- 
sicians of  that  State ;  therefore  the  credit  thereof  belongs  to  our 
colleagues.  But  medical  men  are  accustomed  and  satisfied  to 
see  the  glory  of  their  public  work  go  to  others,  when  humanity 
at  large  and  individuals  are  benefited  and  protected  thereby. 

1  Michigan  Montlily  Bulletin  of  Vital  Statistics,  June,  1899. 


This  little  book  has  been  written  to  place  before  those  phy- 
sicians who  may  not  be  thoroughly  familiar  therewith — 

1.  The  rationale  and  technique  of  irrigations  in  acute  gon- 
orrhoea. 

2.  The  advantages  of  dilatations  and  irrigations  in  chronic 
gonorrhoea. 

3.  The  dangers  of  uncured  gonorrhoea,  and  the  means  of 
locating  the  foci  of  the  disease,  especially  after  its  external 
manifestations  have  subsided. 

4.  To  urge  physicians  to  use  their  influence  for  the  dissem- 
ination of  a  better  understanding  of  the  disease. 

If  in  but  one  instance  these  purposes  are  accomplished,  my 
efforts  to  that  end  will  be  amply  rewarded. 


INDEX. 


Abortion  of  acute  manifestations,  11 

Abscess,  follicular  and  peri-urethral, 
38 

Absence  of  gonococci  from  one  speci- 
men not  conclusive,  130,   137, 
207 
or  reduction  of  sensation  on  ejac- 
ulation, 128 

Accessory  treatment,  34 

Action  of  potassium  permanganate,  8 

Acute  anterior  gonorrhoea,  8 

anterior  gonorrhoea  alone,  rare,  8 
posterior  gonorrhoea,  19 

Adenitis,  gonorrhceal,  see  Lymphade- 
nitis 

Adhesions,  preputial,  41,  88,  90 

Adnexa  invaded  from  posterior  ure- 
thral infection,  21 

Agglutination  of  the  meatios,  136 

Albarran  instillator,  28 

Albuminuria,  42  ;  in  posterior  gonor- 
rhcea,  22 

Alcohol,  36 

Amusements  aid  in  opposing  neuro- 
ses from  gonorrhoea,  34 

Angemia,  42 

Anaesthesia  of  urethra  not  necessary 
in  irrigations,  18 

Ansesthetizing  urethra,  109 

Anterior  irrigations,  12;    technique 
of,  14 

Antinosin  in  inguinal  adenitis,  81 

Antrophors,  20 

Anuclear    epithelium    in  urine  evi- 
dencing infiltration  of  urethra,  205 

Apparent  immunity  from  gonorrhCBa, 
187,  208 

Artificial  oedema  produced  by  irri- 
gations, 11 


Artificial  prolongation  of  coitus,  129 

urethritis    induced  to   ascertain 

presence  of  gonococci,  137,  206 

Asepsis  of  shield  and  nozzles,  14 
of  urethra,  108 

Aspermia,  apparent,  128 

Athletics,  37 

Auto-reinfection  in  gonorrhoea,  170 

Avoidance  of  carrying  infections  to 
patients  by  the  irrigator,  7 

Bacteruria,  144 

Balanitis,  42 

Balanoposthitis,  42 

Ballooning  urethra,  16 

Bangs'  lubricator,  153 

Bartholin! 's  glands  a  frequent  site  of 
residual  gonorrhoea,  8 

Bathing,  34 

Beard  on  sexual  neurasthenia,  83 

Beck,  radiogi'aphy  of  arteriosclerosis, 
55 

Bed,  35 

Beer  test,  206 

Beer-tripper,  171 

B^niqu^  sound,  106 

Berg    on   general  gonorrhceal   infec- 
tion, 74 

Bergson  on  ritual  circumcision,  117 

Beverages,  35 

Bicycling,  37 

Birch-Hirschfeld  on  epididymitis,  57 

Bladder-drainage,  continued,  111 ;  in- 
terrupted, 112 

Bladder,  excessively  strong  solutions 
accidentally  entering,  14,  16 
inflammation  of,  see  Cystitis 
in  health,  immune  to  gonorrhoea, 
22 


214 


INDEX. 


Bleeding  after  urination  in  posterior 
gonorrlicea,  21,  23 
at  or  after  dilatation,  163,  164 
see  Hemorrhage 
Blind  fistulse,  45 

Blindness  from  gonorrhoea,  209,  211 
Bloody  emissions,  122 
Bougie-k-boule,  205 
Bracket  irrigator,  6 
Bubo,  see  Lymphadenitis 
Buller's  dressing  in  gonorrhoeal  oph- 
thalmia, 86 
Buschke  on  skin  diseases  complicat- 
ing gonorrhoea,  116 

Calculi,  urethral,  71 

Carbonated  drinks  prohibited,  35, 
172 

Carcinoma  of  urethra,  200 

Care  of  irrigator,  5 

Casper  ointment,  in  epididymitis,  61, 
65 ;  suspensory  bandage,  64 

Catheter-fever  prevented  by  irriga- 
tions, 12,  162 

Catheter  for  vpashing  urethra  is  repre- 
hensible, 20 

Causes  of  chronic  gonorrhoea,  126 

Caustic  potash  test  for  pus  in  urine, 
11,  144 

Cavernitis,  45 

Centrifuging  urine,  204 

Chancre,  47 

Chancroid,  47 

Chocolate-color  emissions,  122 

Chordee,  47 

Chronic  gonorrhoea,  125 ;  treatment 
of,  145 

Circumcision,  91 ;  ritual,  dangers  of 
traumatism  by,  117  ;  in  France  not 
permitted  except  in  presence  of  a 
physician,  118 

Clap-threads,  68, 145 

Cleanliness  in  irrigations,  13,  17 

Clear  urine  not  a  positive  evidence 
of  health,  144 

Clothing  dilator,  151 

Clots  following  urine,  21 
in  urine,  23 


Cocaine  before  irrigations,  not  neces- 
sary, 18 

Cohesion  of  lips  ol  meatus,  136 

Coitus,  incomplete,  46 

Collodion  to  protect  finger  in  rectal 
exploration,  177 

Colombini  on  general  gonorrhoeal  in- 
fection, 73 

Color  of  discharge  and  color  of  stain, 
142 

Combined  rectal  and  vesical  examina- 
tion of  the  prostate,  180 

Comma  filaments  as  evidence  of  pros- 
tatic disease,  69 

Complications  of  gonorrhoea,  38 
of  posterior  gonorrhoea,  22 

Compressor  as  a  protection  to  posterior 
urethra,  19 

Condoms,  a  cause  of  auto-infection, 
16 

Condom  test,  207 

Condylomata,  48 

Congenital  strictures,  117 

Constitutional  infection,  73 
symptoms  of  gonorrhoea,  22 
treatment,  34 

Covers  for  dilators,  151 

Covyperitis,  50 

Cowper's  glands,  examination  of,  183 

Cred6  method  to  protect  the  new-born 
from  gonorrhoeal  ophthalmia,  209 

Cultm'e  experiments,  208 

Cure,  proofs  of,  202 

Curette  for  urethral  glands,  165 

Cushing  on  gonorrhoeal  peritonitis, 76 

Cystitis,  53 

Cystoscopy  in  enlarged  prostate,  181 

Daily  examinations  necessary,  58,  80 

Dangers  of  irrigation,  14 

Death  from  gonorrhoea,  76,  211 

Defecation  drop,  129 

Defective  irrigation  apparatus,  1 
technique,  1 

De  Keersmaecker  on  chronic  urethri- 
tis, 19 

Diday  on  stains  from  urethral  dis- 
charges, 142 


INDEX. 


215 


Dietetic  irregularities  producing  re- 
currences of  gonorrhoea,  171 

Digital  palpation  of  the  urethral 
adnexa,  173 

Dilatation,  contraindications,  164 

Dilatations,  amount  of,  162  ;  forcible 
not  permitted,  164;  frequency  of, 
162 ;  length  of  each,  162  ;  not  pain- 
ful, 149  ;  technique  of,  160 

Dilator  covers,  151 ;  their  steriliza- 
tion, 152 

Dilators,  manner  of  holding,  151 

Discharge  in  chronic  gonorrhoea,  130  ; 
increased  after  dilatation,  162 ;  in 
posterior  gonorrhoea,  22 

Discharges  of  gonorrhceal  pus  from 
the  posterior  urethra,  131 

Disturbed  digestion  in  gonorrhoea,  12 

Diverticle,  see  Urethral  diverticulum 

Donne's  caustic  potash  test  for  pus  in 
the  urine,  55,  144 

Dressing  glans  after  irrigation,  16 
penis,  113 

Dribbling  of  semen  after  coitus,  139 

"  Drinking  away  a  clap,"  36 

Drop  expressible  from  healthy  ure- 
thra, 84 

Duchastelet  urinal,  112 

Dynamic  influence  of  instruments  in 
the  urethra,  149 

Dysuria  in  posterior  gonorrhoea,  24 

Early  symptoms  of  gonorrhoea,  10 

treatment  necessary,  11 
Ejaculatio  prsecox,  139 
Ejaculations  of  semen,  painful,  138 ; 

premature,  139;  suppressed,  129 
Electrolysis    of    infiltrated    urethral 

glands,  166 
Electrolytic  puncture  of  infiltrations, 

166 
Emissions,  bloody  or  chocolate  color, 
122  ;  painful,  138 ;  premature, 
139;  seminal,  140 
in  posterior  gonorrhoea,  23 ;  from 
irritable  posterior  urethra,  140 
Englisch  on  foreign  bodies    in   the 
urethra,  71 


Eosin  counter-stain  for  microscopic 
specimens,  207 

Epididymitis,  55 

Epispadias,  65 

Epithelium  in  the  urine,  66  ;  thinned, 
an  evidence  of  stricture,  66 

Erections  in  posterior  gonorrhoea,  23 
painful,  82,  138 

Eucaiue  before  irrigation  not  neces- 
sary, 18  ;  in  retention,  109 

Evacuating  bladder  gradually  in  re- 
tention, 109,  110 

Excessive  moisture  at  meatus,  132 
sexual  desire,  133 

Exercise,  36 

Expressing  urethral  secretions,  202 

Expression  urine,  204 

Extra-genital  gonorrhoea,  9 

Eye,  gonorrhceal  inflammation  of,  see 
Ophthalmia 

Failures  in  irrigation  treatment; 
probable  causes  thereof,  1 

Fainting  during  irrigation,  14 

F^lick6  on  irrigations,  1 

Fever,  m-ethral  (catheter-fever),  obvi- 
ated by  irrigations,  12,  162 

Fig-warts,  see  Condylomata 

Filaments  in  the  urine,  144 

Finger  on  the  frequency  of  posterior 
invasion,  19 ;  on  purpura  rheuma- 
tica  as  a  complication  of  gonor- 
rhoea! processes,  116 ;  on  urethro- 
cystitis, 63 ;  on  epididymitis,  56 ; 
on  prostatic  filaments,  69 

Fistula,  urethral,  66 

Flakes  in  the  ui-ine,  144 

Flexible  sounds  to  prepare  the  urethra 
for  dilatations,  149 

Floaters  in  the  urine,  67,  144 

Follicular  abscess,  38 

Folliculitis,  see  Abscess 

von  Frisch  on  examination  of  the 
prostate,  178 

Food,  37 

Force  never  permissible  in  dilatations, 
164 

Foreign  bodies  in  the  urethra,  70  ^ 


216 


INDEX. 


Foreskin,  tight,  in-igation  of,  15 

Frank  on  irrigations,  1 

Frenum,  short  or  rigid,  73 

Fricke's  method  of  strapping  testicle 
(author's  modification),  61 

Fuller  on  seminal  vesiculitis,  119 ; 
on  tuberculosis  of  the  seminal  vesi- 
cles, 122 ;  on  examination  of  the 
seminal  vesicles,  182 

Fulminant  type  of  posterior  gonor- 
rhoea, 27 

Funiculitis,  73 

Fiirbringer  on  floaters  in  the  urine, 
67  ;  on  prostatic  filaments,  69  j  on 
over-treatment,  167 

Genesic  liyperaesthesia,  134 

Gentleness  essential  in  dilatations,  149 

German  statistics  on  death  and  blind- 
ness from  gonorrhoea,  209 

Gerson,  scrotal  elevating  strips,  64 

Gin,  38 

Glands,  urethral,  infiltrated,  syringe 
for  their  injection,  165 ;  curette  and 
electrolytic  needle  for  their  destruc- 
tion, 166 

Glans,  dressing,  after  irrigation,  16 

Gleet,  77 

Goldberg  on  results  of  irrigation 
treatment,  1 

Gonococci  proliferate  by  segmenta- 
tion, 10 

Gonococcicidal  action  of  hot  water, 
11 

Gonococcus,  an  anaerobic  microbe,  11 

Gonocystitis,  120 

Gonorrhoea  and  marriage,  208 

bags,  a  cause  for  auto-infection, 

17 
recurrence  from  marital  excesses, 
169 

Gonorrhoeal  ophthalmia,  85,  209 

Gouley  on  gonocystitis,  120;  on  in- 
cision through  the  rectum  for  ab- 
scess of  seminal  vesicles,  122 

Gout,  77 

Goutte  militaire,  137 

Granules  in  the  lu-ine,  142 


Guiard  on  causes  of  chronicity,  126 ; 
on  classification  of  substances  in 
the  m-ine,  144;  on  floaters  in  the 
m-ine,  67  ;  on  gonorrhoeas  that  are 
chi'onic  from  the  inception,  126, 
135,  185;  on  "little  ejaculations," 
132 ;  on  mechanism  of  gonorrhoeal 
discharge  from  posterior  urethra, 
132 

Guiteras  on  stricture  of  meatus,  118 

Gumma  of  frenum,  39 

Giiterbock  on  prostatic  examination, 
178 

Guyon  on  classification  of  substances 
in  the  ui'ine,  144  ;  classification  of 
urinary  filaments,  70 ;  curved  pos- 
terior dilator,  158;  on  discharges 
simulating  spermatorrhoea,  131 ;  on 
dressing  penis,  113  ;  on  the  dynamic 
influence  of  instruments  in  the  ure- 
thi-a,  149 ;  on  foreign  bodies  about 
glans,  143  ;  on  instillations,  29;  on 
irrigations,  1 ;  on  mechanism  of 
emission  of  gonorrhoeal  discharge 
from  posterior  urethra,  132  ;  modi- 
fication of  Mercier  catheter,  114 ; 
on  normal  mucous  filament,  68  ;  on 
ramonage,  205 ;  retention-catheter, 
111;  soimd,  106;  on  "stammering 
urination,"  103 

HEMATURIA  in  posterior  gonorrhoea, 
23 

Hemorrhage,  77 ;  ex  vacuo,  from  rap- 
idly emptying  the  bladder,  110 

Hsemospermia,  79,  122 

Hairpin  in  tu-ethra,  72 

Hatpin  in  urethra,  72 

Heiman  on  the  gonococcus,  77 

Heitzmann  on  epithelia  in  urine,  66 ; 
on  filaments,  70;  on  gonocystitis, 
122 

Hoffmann  on  examination  of  the  pros- 
tate, 178 

Horand  suspensory  bandage,  64 

Horowitz  on  Cowperitis,  50 

Horseback  riding,  37 

Hydrocele,  79 


INDEX. 


217 


Hydrogen  peroxide  not  a  gonococci- 

cide,  11 
Hyperaesthesia,  149 
Hypospadias,  65 

Immunity,   apparent,  to    gonorrhoea, 

187,  208 
Imperious  urination  in  posterior  gon- 
orrhoea, 24 
Increase  of  discharge  after  dilatation, 

162 
Increasing  intervals  of  treatment  to 

test  progress  of  case,  167 
Incrustated  meatus,  136 
Indications  for  irrigations,  12 
Inefficient  sounds,  148 
Infection   by  apparatus,   precautions 
against,  13 
from  a  sound,  9 ;  from  a  water- 
closet,  9 
Infiltration-augesthesia,  see  Schleich 
Infusions  in  posterior  gonorrhoea,  27 
Inguinal  adenitis,  antinosin  in,  81 
Instillations  of  silver  nitrate  in  pos- 
terior gonorrhoea,  29 
Instrumentation  of  acutely  inflamed 
urethra,  20 
of  the  urethra  or  bladder,  followed 
by  irrigations,  12,  162 
Intervals    between   dilatations,    162 ; 

between  irrigations,  19 
Intravesical  irrigations,  impediments 

to,  31 ;  technique  of,  29 
Intromission  not  necessary  for  acqui- 
sition of  gonorrhoea,  8 
Invasion  of  organism  from  posterior 

urethra,  20 
Irrigation  in  recumbent  posture,  14; 

in  standing  posture,  14 
Irrigation-treatment,  statistics  of  re- 
sults, 1 
Irrigations,  conditions  in  which  they 
can  exercise    no  effect,   165 ;   cure 
ninety  per  cent,  of  gonorrhoeas  with- 
in fourteen  days,  1 ;  indications  for, 
12  ;  prevent  urethral  fever,  12,  162 
Irrigator,  care  of,  6 ;  cleansing  of,  6 ; 
description  of,  2 


Irritative  urethritis  from  treatment  of 

healthy  methra,  69,  167 
Itching  in  urethra,  135 

Jadassohn  on  posterior  gonorrhoea, 
19,  102 

Jamin  on  discharges  simulating  sper- 
matorrhoea, 131 

Janet  on  irrigations,  2,  18  ;  solutions 
employed,  125 ;  treatment  of  chron- 
ic gonorrhoea,  146 

Joly  on  ritual  circumcision,  117 

Klotz  on  the  effect  of  carbonated 
drinks,  36 

Kobner  on  prevention  of  catheter  fe- 
ver, 28 

Kofmann  on  urethral  hemorrhage,  78 

Kollmann  on  cavernitis,  46 ;  electro- 
lytic needle  for  the  destruction  of 
urethral  gland,  166 ;  four-branched 
anterior  dilator,  157  ;  four-branched 
posterior  dilator,  158;  Guyon  curve 
antero-posterior  dilator,  159;  irri- 
gating dilators,  159 ;  photographs 
of  the  urethra,  189 ;  on  psoriasis 
mucosse  urethralis,  201 ;  syringe  for 
urethral  glands,  165 

Lacebatiox  of  urethra  avoided,  150, 
154 

Lacuna  magna  may  arrest  instrument, 

150 
Langlebert  suspensory  bandage,  64 
Latent  gonorrhoea,  168 
Leleneff  on  gonorrhceal  neuroses,  82 
Letzel  on  posterior  gonorrhoea,  102 
Lewis  on  posterior  gonorrhoea,  102 ; 
its    frequency,    102;    infection 
through  the  lymphatics,  115;  semi- 
nal vesiculitis,  119 
"Light  attacks  "  of  gonorrhoea,  126 
Limits  of  dilatation  and  irrigation, 

165 
Linen,  stains  on,  131,  142 
"Little  ejaculations,"  131 
Lowenfeld  on  sexual  neuroses,  83 
Lowered  physical   condition  predis- 
poses to  gonorrhoea,  8 


218 


INDEX. 


Lustgarten  and  Mannaberg  on  pseudo- 

gonococci,  123 
Lydston  on  athletics  in  genito-nri- 

nary  diseases,  37 
Lymphadenitis  gonorrhceica,  80 
Lymphangitis,  81 

Malassez  and  Terrillon  on  epididy- 
mitis, 56 

Malodorous  ■urine,  143 

Marital  reinfection,  169 

Marriage  of  gonorrhoeics,  208 

Massage  of  prostate,  183 

Masturbation,  psychic,  170 

Masturbator's  premature  ejaculations, 
158 

Measuring  size  of  prostate,  180 

Meatometer,  Piffard's,  193 

Meatus,  agglutination  of,  136 ;  exces- 
sive moisture  at,  132  ;  swollen,  4,  10 

Mechanism  of  gonorrhcBal  infection,  8 
of  symptomatology  of  posterior 
gonorrhoea,  21 

Megaloscope,  192 

Mercier  curve  catheters,  114 

Merciu-ic  bichloride  test,  206 ;  in  pos- 
terior gonorrhcBa,  26 

Methylene  blue  in  differentiation  be- 
tween anterior  and  posterior  gon- 
orrhoea, 25;  stain  for  gonococci, 
208 

Michigan's  law  on  the  marriage  of 
gonorrhoeics,  211 

Microscope,  preparing  specimen  for, 
207 

Milking  urethra,  133  ;  maintains  ure- 
throrrhoea,  203 

Moisture,  excessive,  at  meatus,  132 

Morgagnian  crypts,  196,  200 

Morning  drop,  137 

Muco-purulent  filaments,  144 

Mucous  filaments,  144 

Mucus,  urethral,  augmented  early  in 
gonorrhoea,  10 

Murcell  on  urethral  rugosities,  150 

Neissee  on  the  gonococcus,  209 
Neoplasms  in  the  urethra,  166 


Nervous  patients,  irrigations  of,  14 
Neuroses   evoked   by  gonorrhoea,   26 ; 
by  normal  filament,  69 
gonorrhoeal,    82 ;    in    prostatitis, 
107 
Nitze-Oberlaender  tubes,  190 
Noeggerath  on  gonorrhoea  in  women, 

208 
Nogu^s-Wassermanu  diplococcus,  123 
Normal  filament,  its  discovery  as  a 

cause  for  neurasthenia,  69 
Nosophen  in  balanitis  and  balanopos- 
thitis,  43  ;  in  scrotal  erosions  from 
strapping,  63 
Nozzles  for  various  sized  meatus,  4 

mode  of  attachment,  5 
Nuclei  of  urethral  epithelia  thinned 
or  absent  in  stricture,  66 

Oberlaender   anterior  dilator,  154 ; 
antero-posterior  dilator,  159 ;     B^- 
nique  carve  posterior  dilator,  157  ; 
on  carcinoma  of  the  urethra,  200 ; 
on  cavernitis,  46  ;  on  chronic  m'e- 
thritis,  126 ;    on  the   treatment  of 
chronic  gonorrhoea,  146 ;  on  dilata- 
tions, 148;    on  "melting"  infiltra- 
tions, 164 ;  on  splitting  infiltrations, 
166 ;  on  psoriasis  mucosae  urethra- 
lis,  201 
Obstacles  to  dilatation,  154,  164 
Odor  of  urine  changed  by  drugs,  143 
CEdema,  artificial,  induced  by  irriga- 
tions, 11 ;  by  gonorrhcea,  85 
Office  arrangement,  33 
Orcho-epididymitis,  55 
Orgasm  suppressed,  129 
Ophthalmia,  gonorrhoeal,  85,  209 
Otis  on  catarrhal  urethritis,  133 ;  di- 

vulsor,  148 
Over-treatment,  84,  166 

Packing  urethra  to  arrest  bleeding, 
78,  164 

Pain  after  urination  in  posterior  gon- 
orrhoea, 23,  24;  connected  with  an 
attack  of  gonorrhoea,  relieved  by  ir- 
rigations, 11 ;  increased  when  local 


INDEX. 


219 


anaesthetics  have  worn  off,  18  ;    on 
urination    after    dilatations,    pre- 
vented by  irrigation,  161 
Painful  erection,  82 

urination,  10;    absent  in  gonor- 
rhosa,  11 
Painlessness  of  irrigations,  17 
Palpation  of  urethral  adnexa,  173 
Paraphimosis,  86 

Patient,    preparation   of,    for  irriga- 
tions, 12 
Periarthritis,  see  Rheumatism 
Period  of  incubation,  9 
Peritonitis,  gonorrhceal,  76 
Peri-urethral  abscess,  38 
Permanent  catheterization,  112 
Phimosis,  88 
Phosphatui'ia,  144 

Physician's  urethra  infected  from  mi- 
croscopic specimen,  9 
Piffard  meatometer,  193 
Ploss  on  ritual  circumcision,  117 
Pollutions,  101 

Posner  on  condylomata,  50  ;  on  poste- 
rior gonorrhoea,  19 
Posterior  gonorrhoea,  acute,  19; 
avoided  by  iiTigations,  20;  causes 
of,  20  ;  diagnosis  of,  25  ;  evoking 
neurosis,  26 ;  fulminant  type,  treat- 
ment of,  27 ;  presumed  recovery 
without  treatment,  21,  26 ;  strength 
of  irrigation  solutions  in,  26 ;  symp- 
toms, 20 
Posterior  irrigations,    technique   of, 

29;  urethra,  examination  of,  196 
Postures  in  irrigation,  13 
Potassium  permanganate,  strength  of 

solutions,  18 
Premature    discontinuance   of  treat- 
ment, 167  ;    ejaculations  from  mas- 
turbator's  or  other  irritable  poste- 
rior urethra,  139 
Premonitory  symptoms  of  gonorrhoea, 

10 
Preparation  of  patient  for  irrigation, 

12 
Prepuce,    adhesions  of,  41,    88,    91 ; 
tight,  irrigations  of,  15 


Prevention  of  pregnancy,  129 

Prolongation  of  coitus,  129 

Proofs  of  cure  of  gonorrhcea,  202 

Prostate,  massage  of,  183 ;  aided  by 
fixing  prostate  with  a  sound,  183 

Prostatic  examination  by  sound  in  the 
bladder  and  finger  in  the  rectum. 
180  ;  filaments,  69 

Prostatitis,  acute,  102  ;  chronic,  107 

Psoriasis  mucosae  uretliralis  (Ober- 
laender),  201 

Psychic  masturbation,  170 

Psychrophor  to  aiTest  urethral  bleed- 
ing, 164 

Purulent  filaments,  144 

Pus  in  urine,  caustic  potash  test  for, 
11,  55,  144 

Pyuria,  11,  144 

Quiescent  gonorrhcea,  168 

Ramoxage,  205 

Rectal  irrigations  in  prostatitis,  104 
Eecumbent  posture,  irrigating  in,  14 
"Recurrent  "  gonorrhcsa,  168 
Relapse  of  acute  symptoms  from  dila- 
tations avoided  by  irrigations,  161 
Relative  sizes  of  bougies  and  dilators, 

163 
Residual  gonorrhcea,  168 ;  in  women, 

184 
Retention  catheter,  111 

of  urine,  24,  108 
Rheumatism,  gonorrhceal,  114 
Rona  on  posterior  gonorrhoea,  102,  115 
Rugosities  on  floor  of  urethra,  150 

Santal  oil  in  posterior  gonorrhcea,  27 

Sascke  on  urethral  injuries  from  cir- 
cumcision, 118 

Schleich's  infiltration  in  circumcis- 
ion, 92;  in  removal  of  inguinal 
glands,  81 

Scott  on  the  dangers  of  gonorrhcea, 
127 

Scraping  urethra,  205 

Scrotal  erosions  from  strapping,  63 

Second  urine  turbid,  not  an  infallible 
evidence  of  posterior  urethritis,  25 


220 


INDEX. 


Semen,  bloody  or  chocolate  color,  102, 
122  ;  ejaculation  of,  132  ;  premature 
emission  of,  139 

Seminal  dribbling  after  coitus,  139; 
emissions,  101 ;  in  posterior  gonor- 
rhoea, 23 ;  vesicles,  examination  of, 
182  ;  stripping  of,  183  ;  vesiculitis, 
119 

Senn  on  tuberculosis  of  the  genito- 
ui'inary  organs,  56 

Sequelfe  of  gonorrhoea,  38 

Sexual  desire,  excessive,  133 

Shield,  cleansing  of,  7 

Shi-eds  in  the  urine,  144 

Simulated  anterior  gonorrhoea,  140 ; 
spermatorrhoea,  131 

Silver  nitrate  in  posterior  gonorrhoea, 
26 ;  test,  206 

Skin  diseases  complicating  or  follow- 
ing gonorrhoea,  115 

Sounds,  inefficient,  148 

Spermatic  cord,  inflammation  of, 
73 

Spermatorrhoea,  simulated,  131 

Staining  for  gonococci,  207 

Stains  on  linen,  131,  142 

Stammering  urination  (Guyon),  103 

Sterilization  of  dilator  cover,  152 

Sternberg,  smear  preparation,  131 

Stewart,  location  of  seminal  vesicles, 
120 

Stone  in  urethra,  71 

Stopcock,  author's,  4 

"  Strain  "  producing  gonorrhoea,  171 

Straining  in  posterior  gonorrhoea,  24 

Strapping  testicle,  61 

Stricture,  evidenced  by  thinned  ure- 
thral epithelium  in  ui'ine,  66,  117 ; 
tight,  149 

Stripping  seminal  vesicles,  183 

Strong  injections  as  a  cause  of  poste- 
rior gonorrhoea,  20 

Suppositories  in  prostatitis,  105 

Suspensory  bandages,  38  ;  as  a  preven- 
tive of  epididymitis,  57 

Swabbing  urethra,  205 

Swinburne  on  irrigations,  1 

Symptoms  of  acute  gonorrhoea,  10 


Syphilis,  prevention  of  infection  by 

nozzles,  8 
Syringe,    Kollmann's    capillary,    for 

urethral  glands,  165 

Tait  on  the  frequency  of  gonorrhcea, 
208 

Tamponing  urethra,  78,  164 

Taylor  on  extragenital  infection,  9; 
on  the  frequency  of  posterior  infec- 
tion, 19 ;  on  gonocystitis,  121  ; 
definition  of  phimosis,  88;  phimo- 
sis scissors,  44  ;  on  skin  diseases  in 
gonorrhoea,  115 ;  on  slitting  fore- 
skin, 44 

Technique  of  dilatations,  160 

Tenesmus  in  posterior  gonorrhoea,  24 

Thiimmel  on  the  impropriety  of  infect- 
ing a  healthy  urethra  for  purposes 
of  investigation,  74 

Tickling  in  urethra,  135 

Tight  foreskin,  irrigations  in,  15 
strictui'es,  149 

Time  consumed  in  irrigations,  18 

Tobacco,  38  ;  poultices  in  epididymi- 
tis, 65 

Traumatisms  of  the  urethra,  117 

Treatment  of  chronic  gonorrhoea,  145 

"  Tripperfctden,"  67 

"  Tro7npeurs,"  129 

Tuberculosis  of  the  geni to-urinary  or- 
gans, 56,  122 

Tm-bid  urine,  11,  143 

Urethea,  female,  frequent  site  of  re- 
sidual gonorrhoea,  8 

must  not  be  washed  with  a  cathe- 
ter, 20  ;  traumatisms  of,  117 
Urethral  adnexa,  palpation  of,  173 

bleeding,  conti'ol  of,  164 

calculi,  71 

fever  prevented    by   irrigations, 
12,  162 

fistula,  66 

glands,  Kollmann's  syringe  for, 
165 

neoplasms,  166 

rugosities,  150 


INDEX. 


221 


Urethritis  ab  ingestis,  171  ;  ex  libi- 
dine,  170;  irritative,  from  treat- 
ment of  healthy  urethra,  69 

Urethrocystitis,  53 

Urethroprostatic  infection,  123 

Urethrorrhcea  maintained  by  milking 
urethra,  131 

Urethroscope,  author's,  190 

Urethroscopy,  188;  technique  of,  192 

Urethrospasm,  avoided,  150 ;  imped- 
ing dilatations,  163 

Urinal,  Duchastelet,  112 

Urination  drop,  129 

Urination,  increased  frequency  early 
in  gonorrhoea,  10  ;  painful,  10,  11 ; 
painful  at  beginning,  from  incrus- 
tated  meatus,  136  ;  painful  from  local 
and  constitutional  disturbances,  139 

Urine,  brought  in  bottles  useless  for 
examination  of  floaters,  70 ;  urine, 
clear,  144  ;  in  chronic  gonorrhoea, 
142 ;  examination  of,  in  posterior 
gonorrhoea,  25 ;  of  gonorrhoeic 
should  be  examined  daily,  24  ;  mal- 
odorous, 143  ;  retention  of,  11,  24 
108;  scalding,  10,  11;  tubes,  25; 
turbid,  11,  143 


Urotropin,  36 

Verhoogen  on  posterior  urethritis, 

19 
Vesical  tenesmus,  24 
Vesiculitis,  119 

Waiting  for  acute  stage  to  pass  off,  a 

serious  error,  11 
Wasiliew  on  ritual  circumcision,  117 
Weichselbaum  on  condylomata,  48 
White  and  Martin  on  the  early  symp- 
toms of  gonorrhoea,  10  ;  on  posterior 
urethritis,   20 ;  on  albuminuria  in 
posterior  urethritis,  22;    on  balani- 
tis, 42 ;   rectal  irrigator,   104 ;  sus- 
pensory bandage,  64 
White  wine,    young,  producing  ure- 
thritis, 171 
Wife,  danger  of  infecting  from  resid- 
ual gonorrhoea,  168 
Women,  residual  gonorrhoea  in,  184 
Wbssidlo  on  the  need  of  rectal  exam- 
ination, 20 ;  on  prostatitis,  102 ;  on 
stricture,  116 

VON  Zeissl  suspensoiy  bandage,  64 


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